Laserfiche WebLink
STATE OF CALIFORNIA <br /> WATER RESOURCES CONTROOPAgp <br /> FORM `B': UNDERGROUND STORAGE TANK PROGRAM Qo <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ew <br /> ONE ITEM 2 INTERIM PERMIT ❑ 7 PERMANENTLY CLOSED TANK . <br /> 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE F�,,��; <br /> L- """^REMOVED 9 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLEp: / <br /> I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY FARM TANK-YESE] NO <br /> A. OWNERS TANK ID# <br /> B. MANUFACTURED BY. � <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 LEPETROLEUM 6 <br /> C_ I UNLEADED � 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 1 PRODUCT 4 GASAHOL E] 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS D 80 UNKNOWN /ggTE 7 METHANOL �pTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTEHAZARDOUS SUBSTANCE STORED 8 <br /> C.A.S.p <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN A,B,C,&D I (� <br /> A. TYPE OF ❑ 1 DOUBLEWALLED E]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM Eff'2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> Ej 99 OTHER <br /> S. TANK Irl STEEUIRON 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑5 CONCRETE 6 POLYVINYL CHLORIDE 0 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN E] 99 OTHER <br /> C. INTERIOR ❑ I RUBBER LINED 2ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED 95 UNKNOWN'' A— <br /> El SUNING MATERIAL COMPATIBLE WITH 100%METHANOL9 YES E] NO L 9OTHER�MA'✓�/ <br /> D. CORROSION ❑ I POLYETHLENE WRAP �E]�(2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> L'_I <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLEfAU <br /> LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEPOLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETESTEEL CLAD W/FRP <br /> A(U)9 GALVANIZED STEEL A U 95 UNKNOWN OTHER A U S 100%METHANOL COMPATIBLE FRP <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 1 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DA.E LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF <br /> SUBSTA F�REMAINING IN 3. W TANK FILLED WITH <br /> yL� GALLONS I IN <br /> T MATERIAL' E]YES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# <br /> �� <br /> � TANK ID# <br /> CURRENT Apy FpC�ITY ID# roo <br /> )O <br /> APPROVED BY NA '� PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE Q <br /> PERMITE EXPIRATION DATE <br /> j CHECK# PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT# <br /> I BY: <br /> FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />