BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTR OARD Igl; UND ROUND STORAGE TANK PROGRAM907, FORM ORMATIONTANK TANK PERMIT APPLICATION INF COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ; Ca PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK FACILITY ID M 1 NEW PERMIT ❑ 3 RENEWAL ❑ ❑ e TANK REMOVEDr/ 3 MARK ONLY ❑ y AMENDED PERMIT 1:1 6 TEMPORARY TANK CLOSURE ONE ITEM ❑ 2 INTERIM PERMIT FARM TANK -YES LJ NO � I FACILITY/SITE NAME WHERE TANK IS INSTALLED, O I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN -SO SPECIFY BY'. p B. MANUFACTURED O A. OWNERS TANK ID R D. TANK CAPACITY IN GALLONS'. C. YEAR INSTALLED k ITEM C. IF (A.1), ISNOT MARKED,1 OMPNLEADEE E ITEM II. TANK C TENTS IF (A.1), IS MARKED, COMPLETE 2 LEADED ❑ 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e ❑ < GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Q' PRODUCT ❑ 2 WASTE E] 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) ❑ ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF C.A.S. #. HAZARDOUS SUBSTANCE STORED & C A.S. # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH E%TERIOB LINER ❑ 95 UNKNOWN A. TYPE OF SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER Try ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBEAGLASS AEINFORCEO PLASTIC STEELIIRON ❑ 5 CONCRETE ❑ fi POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 81W% METHANOL COMPATIBLE FRP MATERIAL ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHEA ❑ 9 BRONZE 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING UNKNOWN C. INTERIOR ❑ 6 UNLINED 5GN55 LINING LINING ❑ METHANOL? ❑ YES ❑ NO El99OTHER F-1 IS LINING MATERIAL COMPATIBLE WITH 100% ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VI LWAAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION 5 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPPLICABNo A U 95 UNKNOWN A U 99 OTHER E A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY U 3 LINED TRENCH 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 A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE A YA STEEL/IRON A U 2 STAINLESSSTEEL A U 7 STEEL CIADW/FRP A U 8100%METHANOL COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, D WATER MONITORING WELLS P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 99GROUNDWATER P S 95 UNKNOWN OTHE P 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE ON TANK PERMANENTLY CLOSED IN PLACE VI. INFORMATION DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF IN wgsTANK PIu6DWITH INERT MATERIAL? El YES ❑ NO 1. ESTIMATED SUBSTANCE REMAINING wGALLONS UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNODWL -D 'F IS TRUE AND CORRECT. THIS FORM HAS BEEN COMPLETED APPLICANT'S NAME (PRINTED 8 SIGNATURE) k Y# JURISDAL AGENCY FACILITY ID M ER / CHECK# PERMIT AMOUNT WFORM B (6-29-s8) THIS FORM MUST BE ACCOMPAI AGENCY# FACILITY ID M TANK ID # AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Inn= Aur I FEE CODE RECEIPT p BY: FACILITY/SITE APPLICATION, FORM 'A', UNLESS A CNENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _