BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI4 WATER RESOURCES CONTRO OARD `A'Y'. FORM `B': UNDERGROUND STORAGE TANK PRO RAM ;��i® TANK TANK PERMIT APPLICATION INFORMATION '�;, COMPLETE A SEPARATE FORM WITH THE=TERARYTAONK I FORMATION FOR EACH TANK. "" ❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMITe TANK REMOVED ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED OF ❑ FARM TANK-YES❑ NO z FACILITY/SITE NAME WHERE TANK IS INSTALLED: 10 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY BUFACTURED BY: U0GNd It A. OWNERS TANK ID N G D. TANK CAPACITY IN GALLONS: (� C. YEAR INSTALLED I"a II.glF C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,C PLETE ITEM D. B C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.M RDOUS SUBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF tEel OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHERTEEUIRON ❑2 STAINLESSSTEEL ❑3 RBBIGLAS4 ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ONCRETE ❑6 POLYVINYLCHLORIDE ❑T ALUMINUM ❑8100%METHANOL COMPATIBLE RIP MATERULL RONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALNYOIINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR NUNED ❑95 UNKNOWN LINING ❑5 GLASS LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 RBBIGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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. / p 8 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS ' P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONEP S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE REMAINING IN GALLONS IN 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MON2.ESTIMATED SUBSTANCE RREMAIQUANTITY OF INERT MATERIAL? ❑YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY AGENCY N FACILITY ID# TANK ID# COUNTY N JURISDICTION � Mao APPRO D BY NAME PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID k Oy S OS `FZ PERMIT NUMBER PERMIT APPROVAL DAT PERMIT E (RATION DATE CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(3-7-66) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPLICATION, FORM `A',UNLE RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY