BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIAWATER RESOURCES CONTRO ARD TORAGE TANK PROG�i AM i . RG OUND S FORM E . UNDE TANK TANK PERMIT APPLICATION INFORMATION . TAN `� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED r5 TN FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Vl R. MANUFACTURED BY'. 1/l A. OWNERS TANK ID q D. TANK sco CAPACITY IN GALLONS', C.YEAR INSTALLED II. TANK 92NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OlL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.It: HAZARDOUS SUBSTANCE STORED&C.A.S.H 114 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN A.TYPE OF 6 ❑ SYSTEM F—] 2 sINGLEWALLEo F-14 SECONDARY CONTAINMENT ❑ 99 OTHER EELIIRON F—] 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC STSTC B.TANK 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100%METHANOL COMPATIBLE FRP [:] MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ A OTHER F--] 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR F—] 5 GLASS LINING 'L 6 UNLINED ❑ 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 10A METHANOL? fl YES ❑ NO ❑ N OTHER D. CORROSION ❑ 1 POLYEFHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3VINYL 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. SY5TEMTYPE A 1 SUOTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U SINGLE WALLELY A U 2 DOUHLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEELPFION A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 6 100%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 5 1 VISUALOHECK5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S fi PRECISION TESTIN P 5 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 1. ESTIMATEfl DATE LAST USED{MO/YR} SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I Ll I I Lo uT 7 1 CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAME ^ PHONE k WITH AREA CODE k Con 9I � � PERMIT APPROVAL DATE ERMIT EXPIRATION DATE PERMIT NUMBER \\ CHECK k PERMIT AMOUNT 9 RCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A.. RRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY