BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN• WATER RESOURCES CONTR�BOARD FORM B': UNDERGROUND STORAGE TANK PR RAMS TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Z�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED TM/ W FACILITY/SITE NAME WHERE TANK IS INSTALLED: ZZ 7 r(/ Yl� w✓Y-�y( j FARM TANK-YES NO N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IV A. OWNERS TANK ID 4 (J' 1 1 B. MANUFACTURED BY: N C. YEAR INSTALLED bjsLO! D. TANK CAPACITY IN GALLONS: - 900 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. El ITEM D.1 UNLEADED LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑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 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 OUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLPWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM 8100%MEfHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑2 (/T^ LKYO LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASS LINING 6 UNLINED ❑95 KNOWN, ❑ ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D.CORROSION ❑ 1 POLVETHLENE WRAP ❑2 TAR OR ASPHALT VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA N CIRCLE A IFABOVEGROUNO, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A 91 No C. MATERIAL A U 5 ALUMINUM A 16 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 5 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 S VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 1 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMAT QUANTITY OF 1 3.WAS TANK FILLED WITH SUBSTA REMAINING IN IN/E7ATERIAL9 ❑YES ❑ NO GALLONS TH6dFORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW EDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY �lCOUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3I o O ti g tiI 1o 1010 N 1 CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE#WITH AREA CODE pp;q 0 2,.,-Z-- I /i /-- UI&Lk� PERMIT NUMBER �PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIE & A FACILITY/SITE APPLICATION, FORM `A',UNLESS A MKIRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY