BILLING 1985-2000 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN& WATER RESOURCES CONTqoOARD FORM `E'; UNDE GROUND STORAGE TANK PR GRAM ' TANK PERMIT APPLICATION INFORMATION 'S K.t' TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. Z IQ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT/ ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED iQ FACILITYISITE NAME WHERE TANK IS INSTALLED: iy * 1( /fJ 6*_ FARM TANK-YES❑VNO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9J lel 3 A. OWNERS TANK IDH 3 1 B. MANUFACTURED BY: VK Q C. YEAR INSTALLED ov I D. TANK CAPACITY IN GALLONS: 0 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A, 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 LET 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.W 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W IFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 UMINUM ❑ 8 100%METHANOL COMPATI BLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [kr95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASSUNING ❑ 6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 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 95 UNKNOWN A U 99 CTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD WIFRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A& 95 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. 5 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 5 3 VAppSE WELLS P S A ELECTRpNdC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PREC4SIONTESTING S 7 PRESSURETESTING P S 91 NONE P 5 95 UNKNpWN P 5 99 D7HER 0 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY IFORM O�UNTYY## JURISDICTION# AGENCY# FACILITY ID# TANK ID# L2LCI I /T2� L J EI I 1 [ 4 NT LOCAL AGENCY FACI TY ID# APPROVE Y 14AME PHONE#WITH AREA CODE bab NUMBER PERMIT APPROVAL DATE PERM EXPIRATION DATE �d� # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: -29-88) THIS FORMMUST BE ACCOMPANI Y A FACILITYISITE APPLICATION, FORM `A',UNLESS A RENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY