BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

.t„�',Os`.. STATE OF CALIFORN WATER RESOURCES CONTROARD 4 �, , . (FORM `B': UN619GROUND STORAGE TANK PR %. RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. t 0 MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT N;K5 CHANGE Of INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT E] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 08 TANK REMOVED K , N FARM TANK-YES D NO W FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY; filtderVIr K C, YEAR INSTALLED D- TANK CAPACITY IN GALLONS: J. II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL F-� 2 PETROLEUM B. C. 0 1 UNLEADED [:] 2 LEADED 03 DIESEL 3 CHEMICAL PRODUCT OIL � 1 PRODUCT 4 GASAHOL 5 JET FUEL fi AVIATION GAS Q 5 HAZARDOUS 0 80 EMPTY Ej 95 UNKNOWNr:a-2WASTE ❑' 7 METHANOL Ej�4 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /, ! C.A.S. .A #: HAZARDOUS SUBSTANCE STORED&C .S.# 0 e o C J 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOD(A,B,C,&D A.TYPE OF 1 DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM F-] 2 SINGLEWALLED F-1 4 SECONDARY CONTAINMENT 99 OTHER VSTEELPRON F-1 2 STAINLESSSTEEL 0 3 FIBERGLASS Ej 4 STEEL CLAD WIFIBERGLASSREINFORCEDPLASTIC B.TANK 5 CONCRETE F-1 6 POLYVINYLCHLORIDE E] 7 ALUMINUM ❑ 9 100%METHANOL COMPATIBLE FRP MATERIAL �y 9 BRONZE 0 10 GALVANIZED STEEL [:]95 UNKNOWN 0 99 OTHER L❑J 1 RUBBER LINED F-12 ALKYD LINING �3 EPDXY LINING E]4 PHENOLIC LINVNG C. INTERIOR ❑ 5 GLASSLINING UNLINED 0 95 UNKNOWN FINING IS LINING MATERIAL COMPATIBLE WITH 100%MFTHANOL? ❑YES � NO [:] 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP F-1 2 TAR OR ASPHALT El 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION D 91 NONE ❑ 95 UNKNOWN El 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 1 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 9 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U1 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. I P S 1 VISUAL CHECK P Q 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELL ,�r^ u S 7� 1.P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER �,J VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE i. ESTIMATED DATE LAST USED(MOIYRI 2. ESTIMATED IOU OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? � YES NO GALLONS 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# GURRE LOCAL AGENCY FACILITY ID# APPROVED NAM PHONE#WITH AREA CODE s a 7 PERMIT NUMBER PERMIT APPROYXL DA PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: Fdoll ORM 8 I6-29-96) THIS FORM MUST BE ACCOMPANIE FACILITYIS1TE APPLICATION, 'FORM `A',UNLESS A MPENT FORM W HAS BEEN FILED DATA PROCESSING COPY