BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

I N 1 I` yr l.r4qLIF0RNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION •� � ,I,/ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONE(TEM ONLY ❑ 1 NEW PERMIT ED3 RENEWALPERMIT ET5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK-- ❑2 INTERIM PERMIT <AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/BITE NAME WHERE TANK IS In—; f I � F. �'�O�- �- FARM TANK-YES❑ NO � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN 0 0 B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. p A. E21 MOTOR VEHICLE FUEL ❑2 PETROLEUM O. C. 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑A OIL g 1 PRODUCT ❑K GASAHOL �5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ED 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N CA.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 WALED ❑3 SINGLE WALLED WITH EXTERIOR UNEP ❑95 UNKNOWN SYSTEM BNGIE WALLED ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER B.TANK �EEUAgN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CUD WIFIBERG{A55 REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ /ALUMINUM ' ION METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UWXNOW'N ❑99 OTHER C. INTERIOR ❑ 1 RUBBER 11IK0 ❑2 AU(YD LINING ❑3 EPDXY LINING ❑1 PHENOLICUNING LINING ❑ 5 GLASS EKING fi UNUNED 95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP Ln 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑1 FIBERGIASSREINMRCEORIASTIC PROTECTION 5 CATHODIC PROTECTION ❑9I NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PflESSURE A U 3 GRAVITY A U=PIPE NKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRfCHLORID:E(PVC) NKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYPPIPE A U 91 NONEC.MATERIAL A U 5 ALUMINUM A U CONCRETE A' U 7 STEEL CUHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AfU gy UNKNOWN A U "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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P D 4 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P a 6 PRECISION TESTING P 6 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P N MOTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/MRI 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ONO 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 { I LOCAL AGENCY USE ONLY COm�NTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMITA OVAL DATE "BRITT EXPIRATON DATE CHECK I PERMIT AMOUNT NURCI " E AMT. FEE CODE CHECK ft Ti� pECEIPT 1 eY: FORM B(6-29.88) THIS FORM MUST BE ACCOMPANIE L FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED "" DATA PROCFSRINr gTYD..