BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTRO! BARD FORM B': I ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ro MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT U-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK IDK B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N A ❑ 1 MOTOR VEHICLE FUEL 5a2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT [:]4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS El HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.K d v-a-LA t'L ©`t C.A.S.K: /y If ,rill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA ❑%UNKNOWN SYSTEM CR-2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑%OTHER ®'T STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3FIBERGLASS ❑ 4 STEEL CLADWIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%MEMMOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL [-]95 UNKNOWN ❑99 OTHER �y F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOUC UNING C. INTERIOR LINING ❑ 5 GLASS LINING L�51"UNLINED ❑96 UNKNOWN IS UNING MATERIAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER I D.CORROSION ❑ I POLYEIHLENEWRAP W2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 1 B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH ACU S UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCIADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A09 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. O P S 1 VISUAL CHECK S S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 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(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION N AGENCY K FACILITY ID R TANK ID N ffE = Cao 3dac6 CURRENT LOCAL AGENCY FAC TTY IDN APPROVED BY NAYS HONE N WITH AREA CODE GY�LS � Za-sr� PERMIT NUMBER PERMIT APPROVAL DAfE PERMIT EXPIRA TE CMECKM PERMIT AMOUNT SURCHARGEAMT. FEE CODE _RECEIPTN BY: Fwc�� mI FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATN9N, FORM 'A',UNLESS;CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY