BILLING - Laserfiche WebLink

Home Browse Search

V, STATE OF CALIFORN& WATER RESOURCESCONTROARD FORM V: UNDE9GROUND STORAGE TANK PRO RAM TANKTANK PERMIT APPLICATION INFORMATION TANK. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7,PERMANENTLYCLQ5EOI ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE '! TANKREMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: j yCr FARM TANK-YE8❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ZOZ 10 A. OWNERS TANK ID M S. MANUFACTURED BY: v< C.YEAR INSTALLED 8 D. TANK CAPACITY IN GALLONS: (goo 11. TANK 22NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITE A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.p: HAZARDOUS SUBSTANCE STORED&C.A.S.M ■111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A.TYPE OF F-1 1 UBLEWALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANKF-1 5 CONCRETE ❑fi POLYVINYL CHLORIDE ❑ 1 LUMINUM ❑910096 METHANOL COMPATIBLE FRP MATERIAL E] 9 BRONZE ❑ 10 GALVANIZED STEEL WUNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY UNINGn 4pHENOLICUNING C. INTERIOR ❑ 5 GLASS LINING ❑fi UNLINED95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ 3 LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINL.ESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A If I't 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. 8 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS ® Dv P 8 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY R FACILITY ID M TANK ID M � ov o CURRENT LOCAL AGENCY FACInLITY ID MAA „^ APPROVED BY NAME PHONE N WITH AREA CODE v �n I vl o PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK M PERMIT AMOUNT VRCHARGE AMT. FEE CODE EIPT p BY. v FORM B(3-7-66) THIS FORM MUST BE ACCOMPANIED A FACILM ITY/SITE APPLICATION, FORM �A�,UNLESS A ENT FORA' HAS BEEN FILED DATA PROCESSING COPY