BILLING 1985-1996 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI& WATER RESOURCES CONTRj&OARD FORM 'B': UNDE GROUND STORAGE TANK PRO RAM 4�/ TANK PERMIT APPLICATION INFORMATION t " TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTgN�1' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REM V4 FACILITY/SITE NAME WHERE TANK IS INSTALLED: -i j ( /'3IS-54M TANK-YES C I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID E B. MANUFACTURED BY: L C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: D o U C II. TANK CO ENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,C LETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL 3 CHEMICAL PPOOUCT E] 4 OIL PRODUCT [-] 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN L2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.B C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.6 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EKTENIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 AIKYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLICUNING C.INTERIOR LINING 5 GLASS LINING 6 UNUNED ❑95 UNKNOWN ❑ IS LINING MATERAL COMPATIBLE WITH 100%IAET MOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT F-13 VINYLWRAP ❑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 A U I SUCTION A U 2 PRESSURE A U 3 GHAVIIY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I 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 I STEEL/IRON A U 2 STAINLESSSTEEL 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 W/FRP A U B 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. FPP 8 IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WAIER MONITORING WELLS 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 5 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. EST$MATEDDATE LAST USED(MOMA) 2 ESIIMA$EDOUANTIIYOF 3.WAS TANK FILLED WITH SUBS]ANCE HEMAINING IN GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED A SIGNAI URE) DAl E LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION 8 AGENCY 8 FACILITY ID 8 TANK IO 8 = = I / 7:� CURRENT LOCAL AGENCY FACILITY ID$ �-77 APPROVED BY NAME ,/ PHONE 4 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK$ PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• le tDIIM B(8 29-BB) THIS FORM MUST BE ACCOMP N:D BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED- DATA PROCESSING COPY