BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOF9ERGROUND A WATER RESOURCES CON L BOARD ••'.°: `�� FORM 'S': U STORAGE TANK I GRAM ma TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `" �^� z 10 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 CLOSUREffj8-rANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: + S FARM TANK-YES❑ NO 4h. CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY iV A. OWNERS TANK ID# B. MANUFACTURED BY: 1'V C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF{A.7},IS MARKED,COMPLETE ITEM C.IF{A 1�,IS NOT MARKED,COMPLETE ITEM D. A. 0,-Mb OR VEHICLE FUEL ❑ 2 PETROLEUM B. r 1' ,� C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL L ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑ 5 HAZARDOUS El 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW} D. IF NOT MOTOR VEHICLE FUEL,FNTER NAME OF HAZARDOUSUBSTANCE STORIED&C+s-#/l'-f , C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ 1 DOUBLE WALLEO ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM/ ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER `• {,} El 4LARON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE E] 6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE �'-�-�y / �]" QGALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR 1 RUBBER LINED El2 ALKYD LINING F—] 3 EPDXY LINING ❑4 PHENOLIC LINING ' LINING ❑5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER 0.COMMOSION ❑ I�91-YrLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOUG 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 1 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 i 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 STEELIIRO14 A U 2 STAT�IL ESS STEEL A U $POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL / A U 5 ALUMINUM A U 6 COdCRETE A U +'7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 LINKNOWN A U f 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 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 INERT 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(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ro.) I c) In U CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE -D eV-OUJ�o I 1 D l PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRA7tgW DATE CHECK# PERMIT AMOUNT _ SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESSA ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY y