BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI/S WATER RESOURCES CONTROWARD FORM 'B': UNDER`MROUND STORAGE TANK PRO AM =�" TANK TANK PERMIT APPLICATION INFORMATION sm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. __ z MARK ONLY ❑ 1 N PERMIT F-] 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0Z W FACILITY/SITE NAME WHERE TANK IS INSTALLED: b ,L( A FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# v B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Ea-1-PRODUCT ❑ 4 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 OAHAZARDOUS SUBSTANCE STORED&CA.S.# i1 A. A 4 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 OUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Zr2SINGLEWAULED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F--] 7 ALUMINUM E] 8 LOA METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ 2 KYD LINING F-] 3 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING fi UNLINED ❑ UNKNOWN MM F--] IS LINING MATERIAL COMPATIBLE WITHI METHANOL? ❑YES ❑ NO f990THER D.CORROSION ❑ 1 POLYEFHtENEWRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE 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 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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. -slP 1 VISUALCHECK P S 21NVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS S 6 PRECISION TESTIN P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMATED OUANTI OF 3.WAS ANK FILLED WITH R GALLONS SUBSTANCE INER ATERIAL? ❑YES ❑ NO THIS FORb HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY ONO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = = t 33 7- b- 10101c) CURB T LOCAL AGENCY FA L TY IDN APPROVED BY N ME PHONE N WITH AREA CODE PERMIT NUMBER U'C PER IT APP OVALD 7�� PERMI EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAM . (//✓ FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS XPRENT FORM'IV HAS BEEN FILED DATA PROCESSING COPY