BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. n MARK ONLY ❑ I 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: FARM TANK-YES❑ NO ❑ 7 Y� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY °O A. OWNERS TANK ID N \ rj\- �� . `�� B. MANUFACTURED BY: C.YEAR INSTALLED S D. TANK CAPACITY IN GALLONS: (� A IL TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A. F;LI MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL N ❑3 CHEMICAL PRODUCT ❑ 4 OIL �I[ i 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 A C.A.S.N C.A.S.N: .111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,6 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEUIRON ❑2STAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CLAD WIRBERGIASS RENRHM PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLOIIIDE ❑ 7 ALUMINUM ❑810D%MEtWOL COMPATIBLE RP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 4f5-ALMKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING UNING ❑5 GLASS LINING ❑6 UNLINED 1 :"AL1 11 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE NTH 100%MFTMANOLP ❑YES ❑ NO •�❑—��99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FNIERGLASSREINFORCEDPUSTIC 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 0 SUCTION A U 2 PRESSURE A U 3 GRAVITY A B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 10(M 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. PI I VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTI 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 I, ESTIMATED DATE LAST USED(MONRI 2. ESTIMATED OUANTITY OF3. WAS TANK FILLED WITH (J - GALLONS SUBSTANCE REMAINING IN 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&SIGNATURF) 04E •. 1 i 7 11 1 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N m CURRENT LOCAL AGENCY FACILITY ID 4 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK P PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(3 788) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM W,UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY ftw `/