BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORIy�' t WATER RESOURCES CONT G BOARD FORM 'S': UNDERGROUND STORAGE TANK PF o M1 TANK ,,,� TANK PERMIT APPLICATION INFORMATIONm COMPLETE A SEPARATE FORM WITH THE FOLLOWIN5JNf0RMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ;^'.'.. ❑3 RENEWAL PERMIT 5 CHANGE OFINFORMATION El 7 PERMANENTLY K I O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE Cf l FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANKDESCRIPTION OMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY FARM TANK-YES❑ NO N A. OWNERS TANK IDN y B. MANUFACTURED BY. p-Z�jyiq� N C. YEAR INS. LLED D. TANK CAPACITY IN GALLONS: II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A. ),IS NOT MARKED,COMPLETE ITEM A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B' C ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ q OIL 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 OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.H III. TANK CONSTR ION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑q SECONDARY CONTAINMENT ❑99 0 R ❑ 1 STEEL/IRON 2 STAINLESS STEEL B.TANK ❑ ❑ 3FIBERGLASS gSTEEL CLAD WIFIeERGLASSREINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 10096 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED 2 ALKYDLINING ❑ 3 EPDXY LINING C.INTERIOR ❑ NQ�41ENOUC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED #OWN IS LINING MATERIAL COMPATIBLEATH IOD%METHANOL? ❑YESgf HER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ !>KLWRAp ❑ PROTECTION 4 FIBERGLASS REINFORCED PLASTIC ❑5 CATHODIC PROTECTION ❑ gt NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION q U PRESSURE B. CONSTRUCTION A U 1 SINGLE WALLED A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE PVC C. MATERIAL A U 5 ALUMINUM ( ) U FIBERGLASS PIPE A U 91 NONE A U 6CONCRETE A U ] STEEL CLAD W/FRP A 8100%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 SECONDA A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL P S 6 PRECISION TEON TESTING P 3 2 INVENTORY RECONCILIATION P S 3 AD SE WELLS P S 7 PRESSURE TESTING S ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 91 NONE 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 S3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]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 N AGENCY N FACILITY Ip N TANK ID N CURRENT LOCAL AGENCY�LITY ID X 3 / APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRATION DATE 'J� CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESSTFSAMMM A CURRENT FORMA' HAS BEEN FILED ■ DATA PROCESSING COPY