BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA (NATER RESOURCES CONTRCOOARD go UNDERGROUND STORAGE TANK PROGRAM FORM `B': ANK.TANK PERMIT APPLICATION INFORMATION Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T10 ❑7 PERMANENTLY CLOSED ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑B TANK REMOVED � S ❑ 1 NEW PERMIT ❑6 TEMPORARY TANK CLOSURE W EFACILITYISIT;ENA;M;E K ON ❑q AMENDED PERMIT E ITE ❑2 INTERIM PERMIT FARM TANK-YES❑ NO W Q M i� S i� w WHERE TANK IS INSTALLED: gig N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ANUFACTUREO eY'. A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS. O O C.YEAR INSTALLED (A.1),IS NOT MARKED,COMPLETE ITEM D. �- IF(A,1),IS MARKED,COMPLETE ITEM C.IF LEADED ❑3 DIESEL II. TANK C NTENTS c. ❑ I UNLEADED ❑6 AVIATION GAS S A. 1 MOTOR VEHICLE FUEL E] 2 PETROLEUM 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 11 3 CHEMICAL PRODUCT El 80 OIL 7 METHANOL F-1 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS El CAS EMP1V ❑95 UNKNOWN ❑2 WASTE 11 GA.S D HAZAARDOUS SUBSTIANCE STORED&C.A.S.It .#'. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C, D ❑95 UNKNOWN n p�UBLEWALLED ❑3 SINGLE WALLED EXTERIOR LINER ❑99 OTHER A.TYPE OF '�I�i/ ❑4 SECONOAR!CONTAINMNTAINMENT SYSTEM 251NGLEWALLE 1 STEEUIRON ❑2 STAINLESS STEEL E13 FIBERGLASS ❑ 43TEELCNDWIFIBERGNSS REINFORCED PLASTIC ❑ 8100%METHANOL COMPATIBLE FRP B.TANK F-15 CONCRETE El 95 POLYVINYLCHLORIDE ❑7 ALUMINUM 99 OTHER MATERIAL El BRONZE El 10 GALVANIZED STEEL El E] UNKNOWN El ❑2ALKYD LINING ❑ 3EPDXY LINING q,7HENOLICLINING ❑ I RUBBER LINED 195 KNOW/ 1 C.INTERIOR ❑ 5 GLASSUNING ❑ 6 UNLINED 99 OTHEfl L)In LINING El IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ,. NO D.CORROSION dFIBERGLASS REINFORCED PLASTIC ❑2TAR OR ASPHALT 3 LWRAP ElE] 1 POClETHLENE WRAP 95 UNKNOWN ❑99 OTHER PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABUV z PRO SURE u IF UNDERGROUND,BOTH IF APPLICABLE95 UNKNOWN A U 99 OTHER A.SYSTEMTYPE A U 3 LINED TRENCH 77TUF SUCnoN B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 91 NONE A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 81100%METHANOLPIPE CO PATIBLE FRP 6 CONCRETE A U 7 STEEL C. MATERIAL A U 5 ALUMINUM A CLAD W/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 99 OTHER S 1 VISUAL CHECK P S 21NVE ON CTR ENTORV RECONCILIATION PP 9 91VNDOO EEWELLS P S 95EUNKNOWN LECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELL 4 7 P S 6 PRECISIONTESTING P S 7 PRESSURETESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO L ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. PPLICANT'S NAME(PRINTED&SIGNATURE) A ) LOCAL AGENCY USE ONLY TANK ID# AGENCY# FACILITY ID# COUN/gIT(Y# JURISDICTION# � U 6 aElEgl l�-+� PHONE X WITN AREA CODE APPROVED BY NAMIEP CURRENT LOCAL AGENCY FACILITY ID X / F a PERMIT APPROVAL DATE ryC�N PERMIT EXPIRATION DATE PERMIT NUMBER //J I'2� pECEIPT N BY: I`V/I CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE FORM B Is-29-ea) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/OSI APPLICATION PP II ATION PROCESSING A',UNLESS A CURRENT FORMA' HAS BEEN FILED