BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI• WATER RESOURCES CONTROOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION n 7 PAHMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED U FACILITY/SITE NAME WHERE TANK IS INSTALLED: !T FARM TANK-YE8 NO ❑ N W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CA) A. OWNERS TANK IDN A I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS. 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. D;KMOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ i UNLEADED 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL GLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F] 7 ALUMINUM El8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL FLPeUNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING [:] 4 PHENOLIC UNING LINING ❑ C. INTERIOR 5 GLASS LINING �""NING 6 UNLINED Fy�UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI WRAP ❑4 FIBERGLASS REIIIFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE NKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. A �-II P 8 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �4VR' L P S 6 PRECISION TESTING P S 7 PRESSURETESTING S NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLV CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF GALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [::]YES [-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Ml = = I ol a 1 If I D 18101010101 CURRENT LOC AGENCY FACILITY IDN APPROVED BY AME .4^ PHONE x WITH AREA CODE a //b / T1�� Va PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY