BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROODARD ".^^ FORM 'B':L UNDERGROUND STORAGE TANK PROGRAM TANK , .- TANK PERMIT APPLICATION INFORMATION . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z ;O MARK ONLY '-❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/81TE NAME WHERE TANK IS INSTALLED: i - S� .// { i � {-s. g �aE(�"+- FARM TANK-YES NO ❑ FV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CD A. OWNERS TANK IDM r - 'D 8. MANUFACTURED BY: G YEAR INSTALLED - / D. TANK CAPACITY IN GALLONS: i II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ S OIL I PRODUCT ❑ 1 GASAHOL ❑ 5 JET FUEL E]6 AVIATION GAS E]5 HAZARDOUS ❑8O EMPTY [:]95 UNKNOWN F]2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.AD A.TYPE OF ❑ I DOUBLE WAUED ❑3 SINGLE WAUEO MTH EXTERIOR UNER 95 UNKNOWN SYSTEM. ❑2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT 99 OTHER ❑ 1 aumN ❑2 STAINLESS ME. E]3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MAMATERIAL.S.TANK ST❑5 CONCRETE ❑6 POLYVINYL OEL)RDE ❑7 ALUMINUM ❑8 IOOA METHANOL COMPATIBLE FRP•.: ❑9 NaN2E � to GALVANIZED MR � 95 LNIKNowN ❑99 OTHER G INTERIOR ❑ I RJBBERLWW ❑2 ALXYOUNNG ❑ 3 EPDXY LUNO ❑1 PHDgUC UNING LINING ❑ 5.GUSS LNNNG 6 UNLINED 95 UNKNOWN B^.UNGMATUMCDMPATIBLFMTHICOWMETHANOL? El Ya 0 N 99 OTHER D.CORROSION ❑1 POLYERLUNEWAAP F�2 TARORASPHLLT 3 VINYLWRNP 1 RUWAASSREINFORCFDPLASTK; PROTECTION ❑5 CATHODIC PROTECTgN ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 1 A SYSTEM TYPE A U I 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 STEEIARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL - A U 6ALUMINUM A U 5CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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. LP t 1VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3VADOSE WELLS P t S ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P t 6 PRECISION TESTING P t 7 PRESSURE TESTING P t 91 NONE P t 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 7.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [:)YES 0 NO OALLONt THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N `.JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE/WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKS PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPTS BY; ♦�,`• FORM B(6.29-66) THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED