BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFO "4�A WATER RESOURCES CON L BOARD FORM `B': U ERGROUND STORAGE TANK IGRAM „o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ,,,,aa`�`' z 1 0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE NK REMOVE0 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q f qNr &) FARMTANK-YESD NO .♦� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Eti1 A. OWNERS TANK ID N B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM 0. A. ❑ 1 MICS# FrVEHICLE FUEL ❑ 2 PETROLEUM B. { C. 1 UNLEADED 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 qltCT' ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 A57E ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR V[HICLE FUEL,ENTER NAME 4F HAZARDOUS SUYdeT;ANCA StO�tE &C.A.S Nf ' C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.✓4 0 ; A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED [:]4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STE4fi ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE6 POLYVINYL CHLORIDE F-17 ALUMINUM E] 8 100%METHANOL COMPATIBLE FRP MATERIAL 8 BRONZE k 1T kVAY�ED STEEL ❑95 UNKNOWN ❑99 OTHER i EI 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1Oft METHANOL? ❑YES D NO ❑N OTHER ., 7; J D.CORROSION ❑ 1 PO�yET# ENEYIRAP ❑ 2 TARORASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 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 STEEL/IRON r A U 2 STAINL$SS STEEL, ' A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE �F C. MATERIAL I A U 5 ALUMINUM/ A U 6 CONO43ETE A U 7dSTEEL CLAD W/FRP A U 8 100%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. P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE P S 95 UNKNOWN P S 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 I fNERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRD&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY II m FACILITYID N TANK ID k 101 , 11 1��D-- 0 EI 10 = CURRENT LOCAL AGENCY FACILITY ID>r APPROVED BY NAME• E N WITH AREA CODE lw � PERMIT NUMBER PERMIT APPROVAL DATE PERMh EXPIRATION DA CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M BY: FORM Bjr,-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM `A',UNLESS A L ENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY