SITE HISTORY - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOFrIA _ WATER RESOURCES COr0L BOARD .. FORM 'B': UNDE�ROUND STORAGE TANK PROS,,.,.AM TANK TANK PERMIT APPLICATION INFORMATION . i COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �'pro'' z ' t0 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ ERMANENTLY CLOSED TANK ! ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O / FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q FARM TANK-YES❑ NO ❑ (� j 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# B. MANUFACTURED BY: uILCTI C. YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: ( II. TANK 96LNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. EVI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 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.# UK C.A.S.W Ill. TANK CONSTRUCT ON MARK ONE ITEM ONLY IN BOX A,B,C,A D i A.TYPE OF eLE BWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER KNOWN SYSTEM LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER i ( ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE r7 8 100%METHANOL COMPATIBLE FRP MATERIAL i ❑9 BRONZE ❑ 10 GALVANIZED STEEL &NKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 P IC LINING C.INTERIOR LINING ❑5 GLASS UNING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER �f D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 V WRAP ❑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 Eu 1 SU I A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 65P14NQQN U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A t<15 UNKNOWN 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 CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U KNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. t P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS E P S 6 PRECISION TESTING P S 7 PRESSURE TESTING91 NO E P S 95 UNKNOWN P S 99 OTHER i VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH i SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [-]YES ❑ NO ! i THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE i LOCAL AGENCY USE ONLY COUNTY M JURISDICTION II AGENCY N FACILITY ID M TANK ID N 131 ;� -3Eo0101 j CURRENT LOCAL AGENCY FACILITY ID N PHONE It WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �\ CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 �` \\ FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNLESS A CURRENT FORMA' HAS BEEN FILED Q/ DATA-PROCESSING COPY