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 ❑ 7 PERMANENTLY CLOSED TAN - L I ONE ITEM NTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 6) FACILITYISITE NAME WHERE TANK IS INSTALLED: rn FARM TANK-YES❑ NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 10 A. OWNERS TANK IDN B. MANUFACTURED BY: C YEAR INSTALLEDy 7 D. TANK CAPACITY IN GALLONS: W GAJ II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A LEl MOTOR VEHICLE B. A ❑ L 3 CHEMICAL PRODUCT ❑4 OIL PETROLEUM Pri PRODUCT C ❑ 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 .q Alk C.A.S.X: =111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,8,C.8 D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM F2�11GLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STESUIRGN ❑2 STAINLESS STEEL r-13 REERGLASS ❑4 STEEL CLAD WIFI IERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOLIC LINING LINING011 LINING ❑5 GLASS LINING ❑6 UNLINEDra�95UNKNOWN ❑ISUNINGMATERIALCOMPATIBLEWITHIOD%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 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 95 UNKNOWN A U MOTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 190%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 S ' VISUAL CHECK N P JS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S I PRECISION TESTING PP 8 7 PRESSURETESTING P 8 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MONET2. GALLONS ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH y11,N1 SUBSTANCE REMAINING IN INERTMATERIAL7 DYES L] NO /1�7r 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 K JURISDICTION N AGENCY N FACILITY ID N TANK ID N ao 10 10 1 / 1= 10 1 0 10 CURRENT LOCAL AGENCY FACILITY ID• APP O D BY N E PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL PERMIT EXPIRATION DATE RG 30 �g �J11 CHECKN PERMIT AMOUNT I SURCHARG AMT. FEE CODE AECEIPTN BY: FORM B(3-7-8a) THIS FORM MUST BE ACCOMPANIED"BY A FACILITY/SITEAPPLICATIOK FORM `A',UNLESSw-w1RRENT FORM'A' HAS BEEN FILED DATA PROCESS"..