BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIAM WATER RESOURCESCONTROARD FORM 'B': UNDE GROUND STORAGE TANK PRO AM =b TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOW10 INFORMATION FOR EACH TANK. - »� MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 9.2S3 S FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: C.YEAR INSTALLED D.TANK CAPACITY IN GALLONS: SQA IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL F-]3 CHEMICAL PRODUCT D4' / 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ��dO 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.# CAS.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN OK A B,C, D A TYPE OF ❑I DOUBIEWAUED ❑3 SINGLE WALLED NTH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑%OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL WALUMINUM BERGNSS ❑4 STEEL GLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑B 100%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑%OTHER F-11 RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING PHENOLICUNING C. INTERIOR LINING F-15 GLASS LINING ❑ 6 UNUNED %UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE NTH Ion METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALTINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E)91 NONE %UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U91 NONE 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 95 UNKNOWN A U 99 OTHER A U 1 STEELMRON 6AU STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U BERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMCONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELUNKNOWN 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 5 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 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 IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENTL AGENCY FACILITY ID# _ APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHAR EAMT. FEE CODE RECEIPT# BY C FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY7SITE APPLICATION, FORM 'A',UNLESS A CURRENT M'A' HAS BEEN FILED DATA PROCESSING COPY