BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM B': UNDERGROUND STORAGE TANK PROGRAM `" 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 PERMANENTLY CLOSE ANK ONE ITEM El INTERIM PERMIT ❑ L.4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: d5� �, - e5 N FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i O A. OWNERS TANK ID# L) B. MANUFACTURED BY: C. YEAR INSTALLED (/ D. TANK CAPACITY IN GALLONS: w it II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM till 00 A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT �OIL 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 8 C.A.S.# IA C.A.S.#: XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ IIUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LV2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER Q 1 Si,UIRON F-]2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK '�I Z y' CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM F-18100%METHANOL COMPATIBLE FRP MATERIAL 4� ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑,4^ENOLICUNING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED 95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WRM 100%MEDIANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑1 POLYETHLENEWRAP ❑2 TARORASPHALT3 WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODICPROTECTION E]91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLI 04 BLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 9 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL qU p UNKNOWN A U 99 OTHER 1 V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. LLS 1LY P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P B 3 VADOSEWES, 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 1A"� P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE S 95 UNKNOWN P 8 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 ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# o / I U (� o CURRENT LOCAL AGAR FACT IDM APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER G PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT t SURCHARGEAMT. FEECODE RECEIPT# BY: FORM B S-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISRE APPLICATION, FORM `A',UNLESS Ti CURRENT FORMW HASBEENFILED DATA PROCESSING COPY