BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'B': P UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � MARK ONLY [—] 1 'W`FERMIT ❑3 RENEWALPERMIT ❑ 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: CEJ, FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 A. OWNERS TANK IDMANUFACTURED BY: C. YEAR INSTALLED (I/Lik D. TANK CAPACITY IN GALLONS: (� II. TANK CPNTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO LETE ITEM D. tV A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. [Bl-UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT F-1B.4 OIL 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 NAMEOF HAZARDOUS SUBSTANCE STORED 8 C.A.S.E CAS.R: KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ lJOLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM fia2$POLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 51EEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC L TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 LINING 3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR LINING ❑5 GLASS LINING L1,41 UNLINED , 95 UNKNOWN ❑ B LINING MATERIAL COMPATIBLE WITH I NOL. YES ❑99 OTHER 0. CORROSION ❑ 1 POLYETHLENEWRAP EXTAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED MASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV, PIPING INFORMAN 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 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. /' Pk 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS II'/F�TT P6 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 �Y GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [_ NO N �// 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 E JURISDICTION R AGENCY R FACILITY ID R TANK ID S 00 .5- 3 101 1 C, o 1 0 CURRENT LOCAL AGENCY FACILITY IDE APPROVED BY NAME PHONE E WITH AREA CODE PERMIT NUMBER /✓�(l/' PERMIT APPR VAL DATE ER IT EXPIRAT DA !tel/ /jam CHECKS PERMITAMOUNT SURCHARGEANT. FEE CODE RECEIPTX BY: cDRP B 13-zee:) THIS FORM MUST BE ACCOMPANlZrdY A FACILITY/SITE APPLICATION, FORM `A',UNLESS%IORRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY