BILLING PRE 2019 - Laserfiche WebLink

Home Browse Search

say--ams STA N WATER RESOURCES CONTROOARD FO ': 1131ND GROUND STORAGE TANK PROGRAM TANKIAY 21 1009 TANK PERMIT APPLICATION INFORMATION COMPLETEEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. MAR` I T/ J r PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ON I 2 INTERIM IMM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ro l FACILITY/SITE NAME WHERE TANK IS INSTALLED: WAT591,00 S4ELL M/+27- FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# Sol(�-�fS9 (�_� B. MANUFACTURED BY: �}EE C. YEAR INSTALLED ! 6 �p D. TANK CAPACITY IN GALLONS: O 0O d II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A [5?1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ® 1 UNLEADED ❑ 2 LEADED ❑ 3 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ® 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER © 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE F-16 POLYVINYL CHLORIDE F-] 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR 1-11 RUBBER LINED F] 2 ALKYD LINING F-] 3 EPDXY LINING E:] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING © 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 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 U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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& 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 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 S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P 7 PRESSURE TESTING P S 91 NONE 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 INERT MATERIAL? E:]YES ❑ NO THIS FORM HAS14EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLI NTZME(PRI TED&SIGNATOR ,q DATE 1 i LOCAL AG Y USE ONLY COUNTY# JURISDICTION# AGENCY#/ FACILITY ID# TANK ID# aN I I I I EI 1 -1 1010111 -71 -&TD DD1 G . CURRENT LOCAL AGENCY FACILITY ID# APPROVEDA3NE# ITH AREA CODE wafer3 7 - �- � PERMIT NUMBER PERMIT APPROVAL DATE - PERMIT EXPIRATION DATE rL,1 CHECK# PERMIT AMOUNT S HARGE AMT. FEE CODE REQWT T# BY: \\7 FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED ,.FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY