BILLING 1985-1994 (2) - Laserfiche WebLink

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.-�._r ...�-.,. ,..-. ,.„ , ..'*•-._.,7-.�4,�;�+-ayrrv.�.F,.c�yyn;•.-.�.-. r ��If-iFPc-y�.�_�,y�..vrr,;�,a. ..� .. STATE OF CALIFORN WATER RESOURCES CONT OARD FORM `B': UND GROUND STORAGE TANK PR RAM a �� TANK PERMIT APPLICATION INFORMATION NK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFO MATION FOR EACH TANK. . 0 MARK ONLY F-] 1 NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TA ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 32,0 ShMk / P FARM TANK-YES❑ NO ,A I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY IV A. OWNERS TANK ID# B. MANUFACTURED BY: cn C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK_ C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [RI1 MOTOR VEHICLE FUEL [D 2 PETROLEUMB. C. [:] 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-] 3 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BD EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&(D A.TYPE OF ❑ I DOU WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM INGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/IRON ❑ 2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE k�95 7 A UM ❑ 6 10096 METHANOLCOMPATIBL.EFRP MATERIAL ❑ 9 BRONZE ❑ 10 GAL /ZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ALKYD LINING ❑ 3 EPDXY LINING E] 4 PHENOLIC LINING C. INTERIOR �`-� LINING ❑5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 ANCL? ❑YES ❑ NO 299 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAPTAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 71511 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 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVD) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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. P S 1 VISUAL CHEOK � S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELEGTRONIC MONITQR P S 5 GROUND WATER MONITORING WELLS fi PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST US D( R) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YE I`VI GALLONS S ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE} DATE LOCAL AGENCY USE ONLY F JURISDICTION# AGENCY# FACILITY ID# TANK ID# q g0 AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER 7 PERMIT APPROVAL DATE PERMIT EXPIRATIO DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI M Y A FACILITYISITE APPLICATION, FORM `A',UNLESS RRENT FORMA' HAS BEEN FILED v DATA PROCESSING COPY