BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD Qp FORM 'S': UNDERGROUND STORAGE TANK PROGRAMTANK TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE G I FORM WITH THE FOLLOWINRMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM - ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED v 7 FACILITY/BITE NAME WHERE TANK IS INSTALLED: 551 ' - / - FARM TANK-YES❑ NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK ID N _ B. MANUFACTURED BY: / C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MRVEHICLE NEL —12 PETROLEUM D. ',... C. ❑ I UNLEADED ❑2 LEADED E] S DIESEL CHEMICAL PRODUCT ❑ 1 OIL 1 PRODUCT ❑ OASAHOL ❑ 5 JET F ❑ 8 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF n �� HAZARDOUS SUBSTANCE STORED A CA.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,L D A.TYPE OF ❑ 1 WAUFD ❑ 0 SINGLE WALLED VAIN EXTERIOR LINER ❑95 L wcm SYSTEM ' 2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUBN)N ❑2 STAINLESS STEEL ❑2 FIBERGLASS /STEEL CIADW/FIBERGLASS REINFORCED PLASTIC B.MANTERUU. F-15 C IE E]e roLmNna1LORDE ❑ 1 ALUMINUM ❑ A IW-VAIUNOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVAMZED STEEL ❑95 UN00%N OTHER 72)/74"'! C.INTERIOR ❑ I RUBBEAUNED ❑2 LINING B EPDXY LINING ❑1 PHENOLIC LINING LINING ❑5 GLASS WINO 6 LNUNED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER F OflROSION ❑ I POLYEIIAENEWMP ❑1 T ASPHALT ❑ 7 VINh WRAP /FIBERGLASS REINFORCED PLASTIC ROTECTION ❑ 5 CATHODIC PROTECTION E2191 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 9 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION U SINOLE WALLED A U 2 DOUBLE WALLED A U S LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U a POLYVINYL CHLORIDE IPVC) A U I FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL CLAD W/FRP A U a IDD%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 1 IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P t 3VADOSE WELLS P a l ELECTRONIC MONITOR P a 5 GROUND WATER MONITORING WELLS P t. B PRECISION TESTING P t 7 PRESSURE TESTING P S 91 NONE P 0 95 UNKNOWN P ■ 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF S WAS TANK FILLED WITH 7V . I 'f) GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT. APPIJGNT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY t FACILITY ID N TANK IO N Cf�1 ren D `% O C� CURRENT LOCAL AOENCY FACILITY ID P APPROVED BY NAME PHONE I WITH AREA CODE /"iN/c s s� PERMTTNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Y CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT aY; C�t7 cyt/ MIIY R111d9.M1 TNIB TORY YIIRT RF NCPOYBAYIcnmSuru m,erce Me,�rl�inu [lYp SI A. um....,.,,,,,,.,,. .,.,,,,,,, ,,,��--,•-„��