BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

-511-Alk OF CALIFOH WATER RESOURCES CONTBOARD FORM `B': •''��''� UN ERGROUND STORAGE TANK PXG RAM TANK Z-- TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING JNFORMATION FOR EACH TANK. w MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION p" ONE ITEM ❑p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED TANK 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: MAG gjtFARM TANK/-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY �� /S 3'7b •O A. OWNERS TANK IDN 1 B. MANUFACTURED BY: C. YEAR INSTALLED fL W D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. X OTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C 1 UNLEADEDILI 2 LEADED 3 DIESEL HEMICAL PRODUCT 4 OIL ❑ 1PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GASAZARDOUS 80 EMPTY ❑ 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) OTOR VEHICLE FUEL,ENTER NAME OF El HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 0 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER B.TANK ❑ 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E:] B 100%METHANOL COMPATIBLE FRP 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED Fl 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASSREINFORCED 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. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FHP 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOfl P 5 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YH) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES D 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&SIGNAT URE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE t a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE L4ECEIPT N I-OHM B(6-29-88) THIS FORM MUST BE ACCOMPANIE.,tlY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY