BILLING 1985-1997 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN WATER RESOURCES CONTRI&OARD FORM `B': UND GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o ro [FACILITY/ AR;ITEM LY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION c,"'opM ON ❑2 INTERIM PERMIT 7 PERMANENTLY CLOSED TAN❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEDO�E NAME WHERE TANK IS INSTALLED: 1 3 &I I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— � � r/ FARM TANK-YES❑ NO ❑ SO SPEECIFYCIFY A. OWNERS TANK ID# 7 B. MANUFACTURED BY: 10 Ili 73 C. YEAR INSTALLED /y J D. TANK CAPACITY IN GALLONS: 11. TANK C TENTS IF(A.1),IS MARKED;COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ME., EHICLE FUEL ❑ 2 PETROLEUMg C, UNLEADED ❑ 2 LEADED ❑3 DIESEL Q PRODUCT ❑ 4 OIL 1PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS US ❑ 60 EMPTY ❑ ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) EHICLE FUEL,ENTER NAME OFBSTANCE STORED&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8, p C.A.S # A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ❑ ss UNKNOWN SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ gg OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGUSS B.TANK ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑0 106%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER E] 1 RUBBER LINED 2 ALKYD LINING C. INTERIOR ❑ jf�3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑ISLINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO O99 OTHER D. CORROSION ❑ I POLYEfHLENE WRAP ❑2 TAR RASPHALT ❑ 3 VINYL WRAP PROTECTION 5 CATHODIL��`�/ 4 FIBERGLASS REINFORCED PLASTIC C PROTECTION 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 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 99 OTHER 5 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 C. MATERIAL A U 5 ALUMINUM A UA CONCRETE A U STEEL CLAD W/FRP q U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED 9 STEEL A 5 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. ap P S I VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORIN WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN WE P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1_ ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF NK FILLED SUBSTANCE REMAINING IN 3. WASTMATERIAL?AL'WITH GALLONS INERT MATE ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# � /'l / TANK ID# lJ WTP � Q O [PE RENT LOCAL AGENCY=FACILITY # ---�y„7r_•Z/� ^/� APPROVED BY p PHONE#WITH ApEA CODE MITNUMBER //�`// PERMIT APPROVALD TE 2� MIT EKPIp TION IDATE IL 1 CHECK# PERMIT AMOUNTCHARGE vC1I FEE CODE RECEIPT# BY: FORM B(3-7-6B) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY