BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIO WATER RESOURCESCONTROARD FORM V: UNDERGROUND STORAGE TANK PROGRAM l/ TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN2 INFORMATION FOR EACH TANK. MARK ONLYF-] 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE Of INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM / ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE 2 MI FACILITY/SITE NAME WHERE TANK IS INSTALLE A/S FARM TANK-YESETNOEJ Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IG A. OWNERS TANK IO yQNC B. MANUFACTURED BY:06 C. YEAR INSTALLED NUA7/e D. TANK CAPACITY IN GALLONS: .� II. TANK CO TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. NLEADED ❑ 2 LEADED ❑ 3 DIESEL , ❑ 3 CHEMICAL PRODUCT ❑ 4 OILRODUGT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7vETHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME O HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: L A/All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.BD A. TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WMBERGLASS REINFORCED PLASTIC S. TANKAS ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOIy- LINING � F-] 5 GLASS LINING ❑6 UNLINEDUNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL�YES NO ❑ 99 OTHER D.CORROSI 1 POLYETHIENE WRAP ❑2 TAR OR ASPHALT -13 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTI ❑5 CATHODIC PROTECTION 91 NONE No"TIKNOWN ❑ 99 OTHER _ IV. PIPING INFO ATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYP A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTAUCTIOMA 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEELCLAD W/FRP A U a 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Ae95 UNKNOWN A U 99 OTHER V. DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION I� /JPS 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING 0)b A NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLYCLOSEDIN PLACE STIMATED DATE LAST US D(MO/YR) 2. ESTIMATED QUANTITY OF WAS TANK FILLED WITH Y ' SUBSTANCE REMAINING IN ERT MATERIAL? ❑YES E] NO GALLONS THIS FORM Hd BEEN COMPLETED UNDERPENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY V7 I COUNTY# JURISDICTION# AGENCY# �.(c FACILITY ID# v ANK ID# 3 1 1 1 :1 = G lo 10 1 j CU T LOCAL AGENCY FACILITY ID R AP VIED BY NAME ONE N WITH AREA CODE LSCA La �9 �s RMIT NUMBER P MITAPPROVAL ATE PERMITWIRATIO76ATE 7 5 CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(3-7-66) THIS FORM MUST BE:ACCOMPANI D BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A.,JRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY