BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOkAIA WAITER RESOURCES COM-iROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION Qp - MARK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL.PERMIT ❑'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑ 21NTERIMPERMIT ❑A AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: (j/6 FARM TANK-YES❑ NO [3- 1. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ' A. OWNERS TANK IDE B. MANUFACTURED BY: C. YEAR INSTALLED Art`[_. D. TANK CAPACITY IN GALLONS: S C� II. TANK CONTENTS OF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ ❑ I MOTORVEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT E] 1 OIL L 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE C 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C.A.S.E C.A.S.E' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,A D A TYPE OF ❑ I DDOOUBLEWALLED ❑ 3 SINGLE WALLED MIH EXTEROR LINER ❑95 UNKNOWN Qif 9N SYSTEM LYE WALLED ❑ /SECONDARY CONTAINMEM ❑99 OILIER I STEEUIRON ❑2 S ARILESSSTEEL ❑3 FIBERGLASS ❑1 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B'MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE'. ❑ 7 ALUMINUM ❑ 5 10ULMFTHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RABERUNED ❑2 LINING ❑3 EPDXY LINING ❑/PHENOLICUNING LINING ❑ 5 GLASS LINING 6 UNWED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER O. CORROSION ❑ I POLYEIHLENE WRAP ❑ 2 TJ,ROII ASPHALT ❑ 3 VINYL WRAP ❑ /FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 9S UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUNC, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN M U 99 OTHER B. CONSTRUCTION A I SINGLE WALLED U U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 07HEA k 1 STEELIQ4 A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 OALVANIZEDSTEEL 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 t 1VISUAL CHECK P t 2 INVEN70WRECONDILIAlIGN P t 3VADOSE WELLS P t A ELEC7RONICMONHOn P 8 5 GROUND WATER MONITORING WELLS P 8_6 PRECISION TESTING P t 7 PRESSURE TESTING P B 91 NONE P t. 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE UST USED(MO/YRI 2. ESTIMATEOOUANTIIY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TD THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 5 SIGNATURE) DALE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION Y AGENCY E FACILITY ID M TANK ID E l � CU C / Y '' Y =� CURRENT LOCK AGENCY FACILITY 10 f APPROVED BY NAME PHONE E WITH AREA CODE PERMIT NUMBER PERMIT APPROVALOATE PERMIT EXPIRATION DATE CHECK E PfgM1T AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ eY: C, IDHMOM2988) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE.APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HASBEENFILFn