BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA' WATER RESOURCES CONTROV YARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: r ! W - (� ,y. �//� :,L.(/ FARM TANK-VES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# / B. MANUFACTURED BY: 1"414- C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: t)d II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F-11 MOTOR VEHICLE FUEL ❑ 2 P ROLEUM B. FC ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICALPRODUCT 4 OIL ❑ 1 P DUCT ❑4 GASAHOL ❑5 JET .UEL ❑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 - I HAZARDOUS SUBSTANCE STORED&C.A.S.# Gf1 ln � C.A.S.#: I III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH DTERIOR LINER ❑95 UNKNOWN SYSTEM r 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELARON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 110�G,A,LVANIZED STEEL [-]95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBEAUNED El;- `^'D LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING F-15 GLASS LINING In WITH 6 UNLINED ❑ Ir g5 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO ur'99/OTHER D.CORROSION ❑ 1 POEYE7HLENE WRAP ❑ 2 TARORASPHALT ❑3 W LWRAP ❑4 FIBERGLASS REINFORCED PLASTID PROTECTION [:]5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDE OUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 8 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER __-M. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TEST S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED AT LAST USED(MO/YR) 2. ESTIMATED UANTITY OF 3.WAST K FILLED WITH SUBSTAN E E AINING IN GALLONS E TERIAL? E]YES E] NO (� THIS F044 HAS BEEN COMPLETED UNDER PENALTY O PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURT; CALAGEN�FACILITYID# APPRpVEU BY NPHONE N WITH AREA CODE T72-- PERMIT NUMBER PERMIT A►PRO L DAT PERMIT EXPIRATION DATE /e z CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-Ra) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESSA CURRENT FORMA' HASBEENFILED