BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING PFORMATION FOR EACH TANK. z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT EXCHANGE OF INFORMATION ❑ 7PERMANENTLY CLOSED TAN 1 ONE ITEM E] 4 AMENDED PERMIT 2 INTERIM PERMIT ❑ ❑6 TEMPORARY TANK CLOSURE ❑e TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I y- W FARM TANK-YES❑ NO (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK ID# _ B. MANUFACTURED BY: 14, F� C. YEAR INSTALLED 1 , D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C PLETE ITEM ON A_ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT [-] 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATIONGAS ❑5 HAZARDOUS E]80 EMPTY El 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.# +, C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGU WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER SIFEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM [—]6100%METHANOL COMPATIBLEFRP ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING ❑6 UNUNED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 400%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE M111516NKNOWN ❑99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 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&>5 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUMA U 6 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 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. r ! P 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS �YJ P S 6 PRECISION TESTING 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 DATE LAST USED IMO/YR( 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [�ffl 101611 10 10 b CURRENT CAL AGENCY F CILITY IDN APPROVED By PHONE#WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATEV PERMIT EXPIRATION DATE CHECKM PERMIT AMOUNT 1 NURCHARGE AMT. FEE CODE I AcCE1PTN BY' \\1 FORM B(6-29-m) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESSACURRENT FORMA' HAS BEEN FILED ^^TA PROCESSING COPY i