BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIf WATER RESOURCES CONTRO' 'OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1�)i FARM TANK-YES❑ NO jSr Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY =� A. OWNERS TANK ID# Q)�" —�',. I� B. MANUFACTURED BY: NK .� C. YEAR INSTALLED 9 D. TANK CAPACITY IN GALLONS: l p�v V� W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. .k A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 03 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL �<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 8 C.A.S.It C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A. TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM >�Y2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ' STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK � MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑ 5 GLASS UNING X6 UNUNED ❑ 95 UNKNOWN ❑ IS UMNG MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP TAR OR ASPHALT ❑3 VINYL WRAP ❑ 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 Vl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A,Ag> STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CI-ADW/FRP, A U 81DO%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 S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE T USED IMO/YR) 2. ESTIMATED QUANTITY OF ��yyy--- 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN <iE!,��.---OALLON8 INERT MATERIAL? YES E] NO v THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 IEEE E C) I o I (c) IE CURRENTLOOAL AOENCY FACILITY ID# APIRRNW gi$ PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RMITEXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(3.7-BB) THIS FORM MUST BE ACCOMPANI�u dY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A C ARENT FORM'A' HAS BEEN FILED