BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNWD WATER RESOURCES CONTROARD •';':.'�� v • ,A FORM `B': UNDERGROUND STORAGE TANK PR AM TANK TANK PERMIT APPLICATION INFORMATION - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ONE ITEM K.�2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE _ �A3 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO IV CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (�1 A. OWNERS TANK ID# B- MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. el'i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL IJ ' PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 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. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM r! `SSINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 10096 METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-] 1 RUBBER LINED El2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER ��y_�• D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 NYL WRAP ❑ 4 FOERGLASS 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 A th1 SUCTION A(U V2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A(, 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTFEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U 8 100%METHANOL COMPATIBLE ERP 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 CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS `J P 6 PRECISICNTESTIN P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER �l. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE CAST USED{MO/YR} 2. ESTIMATED OUANT" OF 3.WAS TANK FI ED WITH SUBSTANCE REMA NIN N INERT MAT L? ❑YES ❑ NO 4 )44 / A GALLONS THIS FORM eAs BEEN COMPLETED CINDER PENALTY OF PERJUR ,AND TO THE BEST OF MY KNO WLED E,IS TRUE AND CORRECT. APPLIOANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I El I I I to 6 1 1 ol a Td 7tr CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAM PHONE#WITH AREA CODE Ile PERMIT NUMBER PERMIT APPROVAL O#h P RMIT kXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED i A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C RENT FORM`A' HAS BEEN FILED DATA PROCESSING.,COPY "