BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORt* WATER RESOURCES CONTFO BOARD FORM 'B': UND RGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATIONm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWALPERMIT - CHANGE OF INFORMATION o. ONE ITEM 2 NEW PERMIT q AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 7 PERMANENTLY CLOSED TANK B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: !yy I. TANK DESCRIPTION COMPLETE ALL I7EM3-IF UNKNOWN—SO SPECIFY #TANK-YES NO .p A. OWNERS TANK ID# J 'r B. MANUFACTURED BY: I� C. YEAR INSTALLED U fit_. D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. U'�-.L-MOTOR VEHICLE FUEL 112 PETROLEUM B. W C ❑ 1 UNLEADED 2 LEADED CK[3 DIESEL D 3 CHEMICAL PRODUCT 4 OIL � PRODUCT D 4 GASAHOL 5 JET FUEL D6 AVIATION GAS 5 HAZARDOUS 80 EMPTY 95 UNKNOWN 2 WASTE 0 7 MEMANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A TYPE OF ❑1 DOUBLE WALLED 0 3 SINGLE WALLED WITH UTERIOR LINER 95 UNKNOWN SYSTEM ®2 SINGLE WALLED 0 4 SECONDARY CONTAINMENT �j �99 OTHER B.TANK Ey, S1EELARON 0 2 STAINLESS STEEL. ❑3 FIBERGLASS D 4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE [--]6 POLYVINYLCHLORIDE 0 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP 0 9 BRONZE D 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED 0 2ALKYD UNING 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING 5d6 UNLINED 95 UNKNOWN 0ISLINING MATERIAL COMPATIBLE WITH 108%METHANOL? DYES DNO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP IL`I-2 TAR OR ASPHALT 0 3 VINYL WRAP ❑4 RBERGLASSREINFORGED PLASTIC PROTECTION D 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN D 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE IMATERIAtL !AU SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A OTHER TEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4,FIBERGLASS PIPE A U 91 NONE LUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP ALVANI2EO STEEL A U 95 UNKNOWN A U S 100%METHANOL COMPATIBLE FRP 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 P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P g d ELECTRONIC MONITOR P 5 P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 5 GROUNDWATER MONITORING WEL P S 91 NONE P $ 95 UNKNOWN P $ gg OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? DYES THIS ❑ ••^� �...HAS BEEN COMPLETED tU UNDER PENALTY—F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COU I# JURISDICTION# AGENCY# ITY ID p TANK ID M CU LOCAL AGENCY FACILITY ID M APPROVED PHONE#WITH AREA CODE UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AML /o FEE CODE RECEIPTp BY FORM B(6-A-SS) THIS FORM MUST BE ACCOMPA , D BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES ,CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY