BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

' "iiTi{- �'�._,-��,�,-s_r `�'r�•-mar �-�r-`r• -'=, - '- - STATE OF CALIFORN WATER RESOURCES CONT BOARD FORM `B': UND GROUND STORAGE TANK PR RAM �,- TANK TANK PERMIT APPLICATION INFORMATIONo COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. `•••P�`�' MARK ONLY ❑ 1 NEIN PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED s FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: w C. YEAR INSTALLED LG D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ i MOTOR VEHICLE FUEL ❑2 PETROLEUM 8, C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT F OIL �RODUCT ❑4 GASAHOL ❑5 dET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ss OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ',w WU �1 HAZARDOUS SUBSTANCE STORED$CA.S.N �y� y C.A.S,0: V 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.S D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH a7moR LINER 45 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑gg 07}{ER TANX F-11 STEELPRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS [:]4 STEEL CLAD WIRBERGLASS REINFORCE)PLASTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑L:ZUNlN'N)'WMN ❑8 100%METHANOLCOMPATI8LEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑99 OTHER C.INTERIOR ❑ 1 RUBBERUNED ❑2 ALKYOUNING ❑3 EPDXY LINING ❑4 1101OLICUNNG LINING ❑5 GLASSUNING ❑6 UNLINEDUNKNOWN ❑IS UNING MATERIAL COMPATIBLE KITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOICPROTECTION ❑91 Nok 5 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/ 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 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U 8 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL A U 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 I VISUAL CHECK N 2 INVENTORY RECONCILIATION P 8 3 VADbS£WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS i) P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH OALLONB SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT: APPLICANT'S NAME(PRINTED 3 SIGNATURE) DATE LOCAL AGENCY USE ONLY FCURRENTJAZCAL TY* JURISDICTION N AGENCY# FACILITY ID# TANK ID# '7 1 1 1 :1 1 1 1-1 Fo-F .. `� 3 d AGENCY FACILITY ID R APPROVED BY NAME �j PHONE#WITH AREA CODE �l ! e /i�� B R PERMITAPPROVAL DATE RMIT EXPIRATION DATE PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT M BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING cnov