BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROI ')ARD FORM 'B': UNDERKKKKKtROUND STORAGE TANK PROGRAM Y TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIO14 FOR EACH TANK. ro Z 10 MARK ONLY ❑ I NEWPERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 MANENTLY CLO K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED to N FACILITY/SITE NAME WHERE TANK IS INSTALLED: �,/UL .✓ NK-YES❑ NO (� Fi I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R B. MANUFACTURED BY. C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.11,4 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ i MOTOR VEHICLE FUEL Z2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 04011 n 1JIICDUCT ❑4 GASAHOL ❑ 5 J UEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF h HAZARDOUS SUBSTANCE STORED&C.A.S.R J Q�O'n//>Aor C.A.S.N. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,BD A.TYPE OF ❑ I BLEWALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM VNGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL 3ARGLASS ❑ 4STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ ALUMINUM ❑811X1%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 INOLICUNING LINING ❑ 5 GLASS LINING ❑8 UFAINED 95 UNKNOWN ❑ tSUNING MATERALCOMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑'99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑ NYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ N OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDE GROUND,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 SINGLEWALLED A U 2 DOUBLE WALLED A�5 3 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 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U Z STEEL CLAD W/FRP A U 81 OD%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 S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S T PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P B 99 OTHER 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 GALLONSINERT MATERIAL? F]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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION k AGENCY M FACILITY ID R TANK ID k 3g � � Oo d o0 / CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE M WITH AREA CODE C h L72 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE fLiCHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE -'CEIPT• BY: W FORM 6(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED �J DATA PROCESSING COPY