BILLING_1985-2004 - Laserfiche WebLink

Home Browse Search

STATE OF CALL FORK WATER RESOURCES CONTR BOARD FORM `B'; UNDAGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION ® TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWI!a INFORMATION FOR EACH TANK. IG MARK ONLY F-1 1 NEW PERMIT F1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 P MAN ENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE U�T�ANK REMOVEDCA) D ('er He r SM pa- S FARM TANK-YES[:19?l N04 r\) FACILITYISITE NAME WHERE TANK IS INSTALLED: Zt- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 6,-,K I B. MANUFACTURED BY: �l< cn 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,(jOMPLETE ITEM D. A. I`MOTOH VEHICLE FUEL 0 2 PETROLEUM B C 1 UNLEADED L] 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT ❑ 4 OIL Rill"PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 0 5 HAZARDOUS 1-1 80 EMPTY [:] 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.HAZARDOUS SUBSTANCE STORED&C.A.S.N Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF F-] I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER El 95 UNKNOWN SYSTEM F-1 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT [:] 99 OTHER- F-1 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS El 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK El 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F❑] 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL F-] 9 BRONZE El 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-� I RUBBER LINED F-1 2 ALKYD LINING ❑3 EPDXY LINING El 4 PHENOLIC LINING C. INTERIOR 5 GLASSUNING F-] 6 UNLINED 1:195 UNKNOWN LINING F-] 0 IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 0 NO ❑ 99 OTHER D. CORROSION F-1 I POLYETHLENEWRAP ❑ 2 TAR ORASPHALT ❑ 3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [::] 5 CATHODIGPROTECTION ❑91 NONE Ll 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 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 A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U & 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER I V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 9 2 INVENTORY RECONCILIATIONSVADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S "I 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 Al ASUBSTANCE REMAINING 1N INERT MATERIAL? ❑ YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,fS TRUE AND CORRECT. IAPPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUINTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# M I I 1 -1 Li I T-1 -7 --7 1010101��- Fo 6 CURRENT LOC AG CY FACILITY 10# APPROVED BY NAME Y)Q PHONE*WITH AREA CODE -7�V7-:7E c 0 1 LE MIT APPROVAL DA fE PERMIT EXPIRATION DATE PERMIT NUMBER —T� CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: an& AdmL .j FORM B16-29-ss) THIS FORM MUST BE ACCOMPAN10"iFf A FACILITY/SITEAPPLICATioN, FORM FORMA' HAS BEEN FILED DATA PROCESSING COPY