BILLING_1986-2001 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTRO�OARD FORM 'S': UND ROUND STORAGE TANK PRO AM COMPLETE ' TANK TANK PERMIT APPLICATION INFORMATION A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV lll.. D FARM TANK-YES❑ NOlif�f z FACILITY/SITE NAME WHERE TANK IS INSTALLED Im 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID (Ji{/ B. MANUFACTURED BY: OA C. YEAR INSTALLE A/ D. TANK CAPACITY IN GALLONS' QQ W 11. TANK22NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. IV A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM / C. ❑ 1 UNLEADED [—] 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ( ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY [:] 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITIEM/D,BELOW) D, IF NOT MOTOR VEHICLE FUEL,t:NrER NAME HAZARDOUS SUBSTANCE STORED 8 C.A.S.#OF C.A.S.N: ,� N All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF09UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTE / ��/J�22 SlNqll WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK 1 /F-15 CONCRETE F-16 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IG)%METHANOLCOMPADBLEFRP MATERIILF/ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOUC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN LINING 9 �,�//❑ IS LINING MATERIAL COMPATIBLE WITH 100%MEIHAND? �/ YES ❑990THER D. CORROSI I' 1 POLYETHLENE WRAP ❑2 T ASPHALT ❑3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTI ❑5 CATHOOICPROTECTION91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFO MAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTIONCVA SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL 1 / A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP l/ A U 9 GALVANIZEDSTEEL A U 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. (g�//I P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 83 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS '� P 8 6 PRECISION TESTING P 8 7 PRESSUflE TESTING P S 91 NONEP S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F 3.WAS TANK FILLED WITH 1. STIMATED GATE LAST USED(MO/YR) 2. ESTIMATED OUANTITV O SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY EAGENCY ICTION# AGENCY# FACILITY ID# TANK ID# oC) 24 0 6Y IDNAP SY NAME PHONE NWITH AREA CODE O / P T PPROVAL DATE PERMR EXPIRATION DATE N� RECEIPTN BY: OUNT SURCHARGE AMT. FEE CODE FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIEC D A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATINFIENT FORMA' HAS BEEN FILED nATA PROCESSING COPY