BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

S A i c Vr VALIrUKN1A WATER RESOURCES CONTROL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM (az TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I C ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O 7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: ��6 �' r • �_! Ln r-�.>� '>' '/</`� FARM TANK-YES❑ NO © N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY �I A. OWNERS TANK IDM B. MANUFACTURED BY C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S� II. TANK CONTENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(AL1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 1 OIL Q/PROOUCT ❑ A 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 6 C.A.S.N C.A.S.X' III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNEP ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑TANK 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 7 STEEL CLAD wIRBERGLAM REINFORCED PLASTIC B.MATERIAL ❑S CONCRETE ❑6 POLYVINYL CNLORIOE ❑ I ALUMNUM ❑B 100%METHANOL COMPATIBLE RIP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXYUNING ❑1 RU40 CLINING LINING ❑ 5 GLASS LINING ❑8 UNUNED F-195 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL] ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 P(Xmm-BIEWRAP ❑2 TM OI ASPHALT ❑3 WNYLWMP F-11 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 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 U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U3 POLYVINYL CHLORIDE(P/C) A U A FIBERGLASS PIPE A U 91 NONE C MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEELCLAD W/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 8 1 VISUAL CHECK P ! 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P ! A ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P ! 6 PRECISION TESTING P 8 7 PRESSURE TESTING P ! 91 NONE P B 95 UNKNOWN P ! 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESi1MATE0 DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON! 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY 3JURISDICTION � AOE� FACILITY ID! � � TANK ID! CURRENT LOCAL AGENCY FACILITY 10 A APPROVED BY NAM! PHONE P WITH AREA COO! EN 64NO3 Y PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 7 CHECK A PERMIT AMOUNT SURCHARGE AMT. FE[COD! RECEIPT I !T: �,� fORM R(9 29 A81 THIS FORM MUST BE ACCOMPANIED L _�ILITYISITE APPLICATION, FORM 'A',UNLESS A CG..WPFr FORM W HAS BEEERf ___ _ DATA PROCESSING COPY