BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARDG, '� FORM 'B': UNDERGROUND TORAGE TANK PROGRAM TANK PERMIT PPL CATION INFORMATION TANK.COMPLETE ASEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH ZO ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO TANK MARK ONLY ONE ITEM E:] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N / FARM TANK-VES❑ NO +� FACILITY/SITE NAME WHERE TANK IS INSTALLED: M3, (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -p' N A. OWNERS TANKID# 8. MANUFACTURED BY: C.YEARINSTALLED 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. A. Eff 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL E1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.# HAZARDOUS SUBSTANCE STORED&C.A.S.# Aviliq III. TANK CONSTRUCTION MARK ONE ITEM LYIN BOXA,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EKTERIOR UNEP �5 UNKNOWN SYSTEM ❑2 SINGLE WALLED. ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑I STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL rp<UNKNOWN ❑ 99 OTHER [-]1 RUBBER LINE ❑2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑5 GlA55UNING ❑6 UNLINED �UNKNOWN ❑S UNING MATERIAL COMPATIBLE WITH IGD%METHANOL? ❑YES ❑ NO 99 OTHER�� D. CORROSION ❑ I POLYETHLENEWPAP ❑2 TAR OR ASPHALT ❑3 VINYLWAAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE P99'UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 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 TV h5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 5�6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/v,�95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK S 2 9NVENTORY RECONCILIATION P S 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING S ] PRESSURE TE STING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT DATE LAST USED(MO/YR) 2. ESTIMATEDQU INI OF 3. WAS NK FILLED WITH A SUBSTAN E NING IN TERIAL? ❑YES ❑ NO GALLONS THIS&RM HAS BEEN COMPLETED UNDER PENALTY OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# all DD 1ZZ .� OD loll CU N LOCAL AGENCY FACILITY IDN ROVED BY ME PHONE N WITH AREA CODE C /I PERMIT NUMBER PERMIT APPROVAL DATE PE IT EXPIRATION DATE ICHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE 31�7IPT N BY: FORM B(6-29-8B) THIS FORM MUST BE ACCOMPANIED 1Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS NT FORMA' HAS BEEN FILED DATA PROCESSING COPY