BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

OBOARDWATER RESOURCES CONT ' ST`pT11 E OF CALIFORN* FORM B': UNDERGROUND STORAGE TANK PROGRAMf m' TANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK ®5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMITONE ITEM 2 INTERIM PERMIT ❑g TANK REMOVED f Ej 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE FMMTANK-YES❑ NO z FACILITY/SITE NAME WHERE TANK 181NSTALLED: 10 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBE MFY ANUFACTURED BY: A. OWNERSTANKID# /'/ w D. TANK CAPACITY IN GALLONS: Sw G YEAR INSTALLED IA44A<— Lin 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. ❑ B C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL co A. 1 MOTORVEHICLE FUEL ❑ 2 PETROLEUM r-I/KDUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL [;] P 7 METHANOL ❑99 OTHER(DESCRIBE IN IT D,BELOW) F-15 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN 2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# KIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,S D 1 DOUBLEWAl1E0 ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN A.TYPE OF F-1MENT ❑99 OTHER SYSTEM SINGLE WALLED E]4 SECONDARY CONTAIN ❑2 STAINLESS STEEL �3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC 1 STEEL/IRON $100%METHANOL COMPATIBLE FRP S.TANK F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM MATERIAL ❑9 BRONZE 0101 ---BREL ❑95 UNKNOWN ❑99 OTHER 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING ❑1 RUBBER NING L 6 UNLINED 95 UNKNOWN C.INTERIOR ❑5 GLASS LINING LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES F-1 NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR Ofl ASPHALT 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORM11111,11 1 N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A$Y$TEM TYPE AI U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U B 100%METHANOL COMPATIBLE FRP C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U T STEELCLADW/FRP A U 9 GALVANIZED STEEL A 5 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 1VISUAL CHECK 8 21NVENTORY RECONCILIATION P S 3VADOSEWELL3 P S 4ELECTRONIC MONITOR P 8 SGROUNDWATER MONITORING WELL / ' P 6 PflECISION TESTING P S ] PRESSURE TE STING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER ✓✓✓"'�L�L—L—''VyI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TA EILLED WITH 2.ESTIMATED OUA IN OF ATE LAS USED(MO/VR) IN T YkIAL? ❑YES ❑ NO 1. ESTIMATED DSUBSTANCE E INI�IN 7--` GALLONS 11 FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# COUNTY# JURISDICTION# AGENCY# FACILITY ID# U 3 � o � 3 APPRO E BY AME PHONE#WITH AREA CODE CURBS LOCAL AGENCY FACILITY ID# �Qih2 _2 PERMIT APPROVAL DATE PERMIT EXPIRATION GATE PERMIT NUMBER RECEIPT# BY: CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE FORM B(3-7-661 THIS FORM MUST BE ACCOMPANIEU BY A FACILITY/SORE APPLICATION, C OPYA',UNLESS dFIRENT FORMA' HAS BEEN FILED