BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL F RD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED w FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO ❑ PO 1- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD A. OWNERS TANK IDN _3 B. MANUFACTURED BY: u ca C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: uAc- Il. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL F-11 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ ❑2 WASTE ❑ 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.NlC_-- C.A.S.N: III. TANK CONSTRUCTION MARKONEITEM ONLY IN BOXA,0.C,A D A. TYPE OF ❑ I DOUBLEWAl1E0 ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUINON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 M MATERIAL ❑B 100%MEHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXYUNING+ ❑ 4 PHE C. INTERIOR LINING ❑ 5 GLASS UNING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑3 V P ❑4 FIBERGLASS REINFORCED PLASTIC - PROTECTION 0 5 CATHDDICPROTECTION ❑ 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 U 95 A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALIJV A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN__A U 99 OTHER A U 1 STEFUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIB GLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE 5 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? EYES ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION B AGENCY N FACILITY ID M TANK ID N 3a = = I 1 1 4d 21 ,243o0 1 G 13 CURRENT LOCAL AGENCY FAACIr ID APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER „F rJ1J`{/1 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY