Laserfiche WebLink
STATE OF CALIFORW WATER RESOURCES CONT BOARD <br /> FORM l UN RGROUND STORAGE TANK P GRAM ' <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. m <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM 0 2 INTERIM PERMIT 7 PERMANENTLY CLOSED TANK <br /> 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— FARM TANK-YES NO <br /> 50 SPECIFY <br /> A. OWNERS TANK ID# [y <br /> B. MANUFACTURED BY- <br /> C. // <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: e� <br /> 11. TANK CONTENTS IF IRA),IS MARKED,COMPLETE ITEM C.IF(A 7),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL 7 2 PETROLEUM B. C. ❑ 1 UNLEADED �2 LEADED 3 DIESEL <br /> E]3 CHEMICAL PRODUCT E]4 OIL I PRODUCT 4 GASAHOL Ej 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS E]80 EMPTY UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.# <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,S D <br /> [A. TYPE OF ❑1 DOUBLE WALLED Lj3 SINGLE WALLED WITH EXTERIOR LINERYSTEM Ej 2 SINGLE WALLED 95 UNKNOWN <br /> 4 SECONDARYCOMAINMEM g9 OTHER <br /> 1 STEEL/IRON 2 STAINLESSSTEEL0 3 FIBERGLASS 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> ANK 5 CONCRETEATERIAL 6 POLYVINYLCHLORIDE 7 ALUMINUM 6100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL IsUNKNOWN 99 OTHER <br /> C.INTERIOR 1RUBBER LINED 2ALKY)UNING 3EPDXYLINING 4PHENOUC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED <br /> � <br /> UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? YES ONO 5;y NOTHER— _h j< <br /> O.CORROSION ❑ 1 POLYETHLENEWRAP 2TAR OR ASPHALT 3 VINYL WRAP r❑-�4 FIBERGLASS REINFORCED PLASTIC <br /> LrJ <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 91 NONE A 95 UNKNOWN A U 99 OTHER <br /> A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE C/95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> 99 OTHER <br /> A U 99 THEfl <br /> C.MATERIAL A U 5 ALUMINUM A U B CONCRETE <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U CLAD Ill U 8100%METHANOL COMPATIBLE FRP <br /> �PRECV. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> ISION <br /> P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P a 4 ELECTRONIC MONITOR P a s GROUND WATER MONITORING WELLS.,, I,lr <br /> P 8 7 PRESSURE TESTING <br /> 8 1 NONE P a 95 UNKNOWN P 8 99 OTHER <br /> '1 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> i.ESTIMATED DATE LAST USED(MO/Vq) .i <br /> Ktol 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? <br /> Ir(A OALLONB YES ONO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTNA <br /> ED 8 SIGTURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> 3 FACILITY ID# TANK ID# <br /> DD � 7 S DOD / <br /> CURRENT AL AGENCY FACILITY ID# <br /> APEPHONE M WITH AREA CODE <br /> PERMIT NUMBER <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT 4URCHARGE AMT, <br /> FEE CODE RECEIPT# <br /> BY: <br /> FORMB(6-29-88) THIS FORM MUST BE ACCOMPANNEOM FACILITY/SITE APPLICATION, FORM 'A'' <br /> UNLESS A(WA-RENT FORMA' HASSEEN FILED <br /> DATA PROCESSING COPY 4 <br />