BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIJ WATER RESOURCES CONTIOBOARD FORM 'B': UND GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION y � COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ MARK ONLY ❑ I NEWPERMIT 3 RENEWAL PERMITI C ONE ITEM ❑ 2INTO ❑S CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED TANK INTERIM 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY L FARM/$ITE NAME WHERE TANK IS INSTALLED: (J. W - -S � TANK-YES❑ NO 1--► I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM Ta C. a I UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 0 OIL 1 PRODUCT ❑d GASOHOL ❑ 5 JET FUEL ❑ 6 AVIATIONGAB 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) U IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S.C.A.S.p i CAS p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D TYPE OF 1 BLE 3 SINGLE `UU A THEXT SYSTEM ❑2 SSIINGE WALLED0 ❑ /SECONOARI'LCONT NMEMED INTH RIOfl LINES ❑N OTUNKHER TANK ❑ I S7EELIIRON :::: EEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED FUSTIC B MATERIAL ❑ 5 CONCRETE HLORIDE 7 ALUMINUM ❑ ❑6100%METMANOL COMPATIBLE FRP ❑9 BRONZE STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBERUNEO ❑2 AUDD LINING ❑ 3 EPDXY LINING ❑ 1 PHENOLICUNING LINING ❑5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYMENEWRAP ❑2TAR Ofl ASPHALT ❑ 3VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER iIV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE OTHE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRA�WU LIN NO B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUOLE WALLED A U 3 LINE �P �� U 99 OTHERA U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLU 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FqP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 810096 METHANOL COMPATIBLE FRP 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S d ELECTRONIC MONITOR P 6 5 GROUND WAT�MONITORING WELLS P 5 5 PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N 3 � CURSE LOCAL AGENCY FACILITY ID APPROVED BY NAME PHONE F W17N AREA CODE 0 _ 3� PEPYIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE I CHECK/ PERMIT AMOUNT i -- URCHARGE AMT. FEE CODE4clepor.NT IPT I BY: m0M A(6.>nAPI THIS FORM MUST RF ACCOMPANIFD BY A FACILITY/SITE APPLICATION, FOPPA 'P�,Ur71PI•'A• NAr nFr.l FP FD