BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORw1 WATER RESOURCES CONT. _ BOARD I^� FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK �/ TANK PERMIT APPLICATION INFORMATION yo y'rAo FOLLOWING INFORMATION FOR EACH TANK. COMPLETE A SEPARATE FORM WITH THEZ to MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT �HANGE OF INFORMATION ❑ 7 WWNENTLY CL K ONE ITEM E] B 2 INTERIM PERMIT ❑ I AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED Q --TT ! W FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� jAr <,—/p?,C MT FARM TANK-YES NO ❑ fV I. TANK DESCRIPTION COMPLETE TEMB-IF UNKNOWN-80 SPECIFY LO A. OWNERS TANK ID E B. MANUFACTURED BY: to C. YEAR INSTALLED {.Ii D. TANK CAPACITY IN GALLONS: 0 Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 1 OIL ❑ I PRODUCT ❑ A GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPIY ❑95 UNKNOWN ❑ 2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.F CAS,A: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTEROR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUBION ❑ 2 STNNLESS STEEL ❑3 FIBERGLASS ❑K STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORDE ❑7 ALUMINUM E]8 IW%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RIBBER UNEO ❑2 ALKYD LINING ❑3 EPDXY LINING ❑K PHENOLIC LINING LINING ❑ 5 GLASS LWING ❑ 8 UNUNFD ❑95 UNKNOWN ❑ IS LINING MATERAL COMPATIBLE WITH 100%METRANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION F-1I POLYEREFNEWRAP ❑2 TMORASRIALT ❑3 VINYLWMP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC NpTECTKkI ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 IW%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. S ( VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S B PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY Y JURISDICTION E AGENCY E FACILITY ID E TANK ID I 3 LFF]� = I 1 14 y z a : CURRENT LOCAL AGENCY FACILITY I w,V!7_' / j APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT OV PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �qr v CHECKI PERMIT AMOUNT SURCHARGE AMT. FEE CODE 'ECEIPTI FORM B(e-29-N) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED ///