BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z LO MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6//TEMPORARY TANK CLOSURE TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4t FARM TANK-YES❑ NO CA) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY O IV A. OWNERS TANK ID# I I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: It. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM e. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑5 JEF 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 ❑ I OUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 02�2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK I MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED MEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING nyPHENOUC LINING LINING ❑5 GLASS UNING ❑6 UNLINED 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2TAR OR ASPHALT n VINYLWRAP ❑ 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 7m 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 AU 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A8 CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A�S 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. 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WA STANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? ❑YES ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D U y "5) 1(�-' i CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE •�1,�5 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT RCHARGE AMT. FEE CODE RECEIPT# V I��FORM B S-29-98) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A bTARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY