BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN18 WATER RESOURCES CONTRIOOARD (az FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 147 MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIMPERMIT ❑ 4 AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE �ANK REMOVED Q I N FACILITY/SITE NAME WHERE TANK IS INSTALLED: a n roe FARMTANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# �4 bl B. MANUFACTURED BY: C. YEAR INSTALLED I q II. TANK CONTENTS IF(A,1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 2_1'MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED Ef'72EADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL EEt 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER Lfr_95 UNKNOWN SYSTEM ❑ 2 SINGLEWALIED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER �EUIRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑ 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-] 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR IN NG R ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN . 4 [:] ISUNING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES E] NO OTHER LA&kk D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VI P ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A a5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U5 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 S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 6 7 PRESSURETESTING P S 91 NONE (D)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 [_-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY C/) COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ,)- ► J a6 CURRENT LOCAL A A ITY ID#e I APPROVED BY NAMP PHONE#WITH AREA CODE PERMIT NUMBER CJ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: is FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AIMENT FORMA' HAS BEEN FILED DATA PROCESSING COPY