BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA, WATER RESOURCES CONTROL HOARD FORM 'S': UNDERGROUND STORAGE TANK PRO AMS TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING " MATION FOR EACH TANK ZO MARK ONLY -❑ 1 NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 TANK ERMANENTLY CLOSFDT ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑e TANK REMOVED w FACILITY/SITE NAME WHERE TANK IS INSTALLED: c a C,RMM TANK-YES❑ NO O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Cly CD A. OWNERS TANK 10 N B. MANUFACTURED BY: ��11 C.YEAR INSTA D. TANK CAPACITY IN GALLONS: (/V It. TANK C TENTS IF(A1),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 OIL 1 ❑1 GASAHOL ❑ 5 JET R1EL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑-99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CA.S.N: HAZARDOUS SUBSTANCE STORED 6 CAS.N 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A TYPE OF ❑ 1 DOUNEWAUID ❑3 SINGLE WALLED WITH WERK)R UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRJN ❑2 STAINIFSS STEEL ❑3 FIBERGLASS ❑A STEEL CLAD W/FIBERGLASS REINFORCED KAM L TANK - ❑6 coNcRETE ❑6 POLYOXCHLOPoOE ❑ 7 ALUMINUM ❑6 100%MMMOL COMPATIBLE FRP MATERIAL._ ❑9 BRONZE ❑ 10 GALVANIZED SIS ❑95 UNKNOW ❑99 OTHER ❑1 RUBBBHNE) ❑2 AUIYD UNING ❑3 EPW LIMING ❑1 PHENOLIC UNING G INTERIOR 5 GU59 LWOLG ❑6 LNLUNED ❑95 UNKNOWN LINING - O IS UNNG MATERIAL COMPATIBLE WITH 1001LMETHANOL7 DYES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHENEWRAP - ❑2 TAR ORASPHALT ❑3 VIHYLWAAP ❑1 RBERGM RONFOECED R/SDC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 IMma ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U i 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 1 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 STEEUWON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A RBERGLASSPIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FTP A U B 1009E METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEER 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 1VISUAL CHECK P 8 2 INVENTORY RECONpLAT10N P S 3VADOSE WELLS P B 1 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 6 PRECLSIONTESTING P 5 7 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING W aAuorM W ERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,ISTRUEAND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION N AGENCY B FACILITY ID N TANK ID N = = I I I ( I 6U CURRENT LOCAL AGENCY FACILITY 10 N j 4APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT ATE PERMIT EXPIRATION DATE is-g9 CHECK/ PERYIT AYOUNT SURCHARGE AMT. FEE CODE RECEIPT& BY: Is FORM a(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACLLTTY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY