SU0007710_SSCRPT - Laserfiche WebLink

Home Browse Search

STATE OF CA,L IFORNU (MATER RESOURCES CONTRA' )OARl7 FORM `B'° UNDt{GROUND STORAGE TANK PROOVRAMp TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .� MARK ONLY ❑ I NEW PERM(1 ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ I PERMANENT(Y( D TANK ONE ITEM E-12 INTFRIM PERMIT ❑4 AMENDED PERMIT PERMIT / ❑ b TEMPORARY TANK CLOSURE ❑8 TANK REMO IT FACILY/SITE NAME WHERE TANK IS INSTALLED: 312- T U./ Trac FARM TANK-YES❑ N •A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDM 1 B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: d O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(at),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ I UNLEADED ❑2 LEADED El3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5.TET FUFL � VIATION 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 d CA.S.M C.A.S.M: 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 B.TANK ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-1TIC 3 FIBERGAASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL � ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL LJ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN ❑ SJNINGMATERIAL COMPATIBLE WiTl 1Iw%METHANOL, ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETUNEWRAP ❑ 2 TAR OR ASPHALT [❑3 NYL WRAP ❑a 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 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/FAP A U 8 100%METHANOL COMPATIBLE FRP A U 7 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 5 2 INVENTORY RECONGLiATlON P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOP P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONF P S 95 UNKNOWN P S 99 CHER 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY A JURISDICTION M AGENCY K FACILITY ID# TANK ID M I ! I I I 1610 -,- l `� I l ol ul l CURRENT LOCAL AGENCY FACILITY ID R APPROVED BY NAME PHONE K WITH AREA CODE Ir,--WY 3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK A PERMIT AMOUNT _ SURCHARGE AMT. FEE CODE RECEIPT K gY: FORM,B(6-29-88) THIS FORM MUST BE ACCOMPAK. /Y A FACILITY/sm APPLICATION, FORM `A',UNLESS ALURRENT FORM'A' HAS BEEN FILED