BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA `, WATER RESOURCES CONTRQ'K'SOARD NK PRO A FORM `B': GROUND STORAGE TAM TANK TANK PERMIT APPLICATION INFORMATION ^ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ . Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E�5 CHANGE OF INFORMATION ❑ 7❑ PERMANENTLYC/ ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 4116 I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERSTANKID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-] 3 CHEMICAL PRODUCT ❑ 4 OIL !CJ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL [:] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY E]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.# Jv 0 C A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D I UBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER F795 UNKNOWN A.TYPE OF ❑ SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON E] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONOETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR E] 1 RUBBER LINED ❑2AUKYDLINING F__] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LAKING 6 UNLINED ❑95 UNKNOWN '�/,I ❑ ISUNING MATERIAL COMPATIBLE WITH IDA METHANOL4 ❑YES ❑ NO OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE �UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE EMA' TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER UCTION A U 1 SINGLEWALLED 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE L A U 5 ALUMINUM A U�(i CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(/U�5 UNKNOWN A U 99 OTHER 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 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED TE LAST USED(MO/YR) 2 ESTIM TED QUANTITY OF 3 VIPS TANK FILLED WITH S A E REMAINING IN GALLONS 4A MATERIAL? ❑YES EJ NO] THIS FOAM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KN WLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ? d CURRENT LOCAL AGENCY FACILITY ID# AplgpOVED BY NA PHONE#WITH AREA CODE MITNUAIBER PERMIT APPROVAL DATE [/ PiRMIT9EXPIFIATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM `A',UNLESS A C RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY