BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

TANK TANK PERMIT APPLICATION INFORMATION s , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT <CNGEOF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 7 FACILITY/SITE NAME WHERE TANK IS INSTALLED- 3 g FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY to A. OWNERS TANK ID N Q B. MANUFACTURED BY: C. YEAR INSTALLED (�(. D. TANK CAPACITY IN GALLONS. A 11. TANK CqNTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,C014PLETE ITEM D. N A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 0 C. ' I UNLEADED ❑2 LEADED ❑3 DIESEL N ❑ 3 CHEMICAL PRODUCT ❑ 1 OIL I PRODUCT ❑ A 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 6 C.A.S.N C A.S.N. ,LII). TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED MTH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ A SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/ROH ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CUD W/FIBERGLASS PfNWRGED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL C41ORCE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZF ❑ 10 GALVAMZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RRBERUNED ❑2 AMC LINING ❑ 3 EPDXY LINING ❑1 PHENOLIC LINING LINING ❑ 5 GLASS LNOC ❑6 LPIUNED 1 ❑95 UNKNOWN ❑ IS LINING MATERAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYEI/IENE WRAP ❑2 TARORASPHAJ ❑3 WNYLWRAP ❑1 FIBERGLAS$REINFORGED 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 I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER I B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U %UNKNOWN A U N OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE LPVCI A U A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAO W/FRP A U B 1D%METHANOL COMPATIBLE FHP 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S < ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S "OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL° ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APP LICANT'S NAME(PRINTED A SIGNATURE) Da E I I � LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK 10 N DO aa57� .. CURAEtjT LOCAL AGENCY FACILITY IDI APPROVE NAME Irk— I'f-1 PHONE P WITH AREA CODE iw I PERMIT NUMBER PEgYLTAMROYAL DATE PERMfT EXNNATIOM DATE i CHECK A PERMIT AMOUNT SURCHARGE AMT. FEE CODE gECEUT A BC i FORM B(3 7 M) THIS FORM MUST BE ACCOMPANIEDBYAFACILMI LYE APKicA TION, FORM W,UNLESS A CURRENT FORM-A' NAS BEEN flLED �DATA PROCESSING COPY