BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROP -OD FORM 'B': UNDEftktrUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION ® , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 75 6' in e FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 4p Ono IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑3 DIESEL CD F-13 CHEMICAL PRODUCT ❑4 OIL 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 OF ^ HAZARDOUS SUBSTANCE STORED&C.A.S.# R C.A.S.W All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM D--SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCREI-E ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-] 1 RUBBER LINED ❑ 2 ALKYDUNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑5 GlA55LINING ❑6 UNLINED UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 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 99 OTHER B. CONSTRUCTION A41 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 0 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS y/\ P 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 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 1104 1 SUBSTANCE REMAINING INGALLONS 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY C OUNTY* JURISDICTION# AGENCY# FACILITY ID# TANK ID# 010 007 ODoCALAGENCY FACILITY D# APPROVED BY NIZMf, PHONE#WITH AREA CODE BER PERMIT APPROVAL DA E PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI A FACILRY/SITE APPLICATION, FORM`A',UNLESS RENT FORM W NAS BEEN FILED DATA PROCESSING COPY