BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIM WATER RESOURCES CONTR ftARD ),j FORM 'S'; UNDERGROUND STORAGE TANK PROGRAM { . TANK.. TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 7L. MARK ONLY `..❑ I NEW PERMIT ❑3 RENEWAL PERMIT n 5 CHANGE OF INFORMATION 71 AMENDED PERNENTLY CL SEO TANK`l . u ONE ITEM - ❑2 INTERIM PERMIT ❑ MIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ?1_00QRM TANK-YES❑ NO ❑ N 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A OWNERS TANK ID N �1�� B. MANUFACTURED BY: CL3 C. YEAR INSTALLED - D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED El3 DIESEL ❑ 3 CHEMICAL PRODUCT E] A OIL ❑ 1 PRODUCT ❑< GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY E]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 6 CA.S.M C.A.S.p: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A O A TYPE OF ❑ I DOUSLEWAUB7 ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM. ❑2SINGLEWAUM ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER f7 S7FELIRON ❑2 STAINLESS STEEL E] RGU 3 FIBESS ❑A STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B MATTERIAL. ❑ 5 WNCRUE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 Kam LWM ❑2 ALM LINING ❑3 EPDXYLWIW ❑/PHENOUCUNING LINING ❑ 5 GUSSUNW ❑6 UNLINED ❑ 95 UNKNOWN ED IS:INWGWTERALCOIAPAT9YEMTH10DIIMErKQa7 ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WIMP 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PIOTEMON ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASSPIPE A U 91 NONE C. MATERIAL - A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 0 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P 8 A ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 0 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST UAli(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [jNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 0 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 9 JURISDICTION Y AGENCY N FACILITY ID N TANK ID N m [�] I I I /I G ; CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE 1 WITH AREA CODE 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I� CHECK 1 PERMIT AMOUNT RCHARGE AMT. FEE CODE �ECEIPT/ BY: �,,�• FORMB(6-29-80) THIS FORM MUST BE ACCOMPANIED BY A FACILITYVSITE APPLICATION, FORM 'A',UNLESSA CURRENT FORMA' HASBEENFILED