BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN' WATER RESOURCES CONTR - ARD PRAM _ o UND�ROUND STORAGE TANK . FORM B • � TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. ` - 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED T 1 NEW PERMIT 3 RENEWAL PERMIT 0 6 TANK REMOVED CLOSED ONLY E] 4 AMENDED PERMIT 06 TEMPORARY TANK CLOSURE z 1 ONE ITEM � 2 INTERIM PERMIT i FARM TANK-YES❑ NO O FIII!! III ACILITY/SITE NAME WHERE TANK IS INSTALLED- I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY f B. MANUFACTURED BY: cncn A. OWNERS TANK ID# O fig D. TANK CAPACITY IN GALLONS: �+ C. YEAR INSTALLED I. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE IT�D LEADED 3 DIESEL A. ❑1 MOTOR VEHICLE FUEL 2 PET LEUM B. ❑3 CHEMICAL PRODUCT OIL 1 P UCT ❑4 GASAHOL D 5 JET FUEL �6 AVIATION GAS 0 95 UNKNOWN 2 WASTE ❑7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS 0 BO EMPTY D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFs C.A.S. W HAZARDOUS SUBSTANCE STORED&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 F-1 95 UNKNOWN SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER i EEL/IRON 2 STAINLESS STEEL F-] 3 RBERGLASS 4 STEEL CLAD WlFIBERGLASS REINFORCED PLASTIC 1 B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE F-1 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL [-].95 UNKNOWN 99 OTHER 1 RUBBER LINED F-1 2 ALKYD LINING 0 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING El 6 UNLINED M-JrUNKNOWN LINING ISllNINGMATERIAL COMPATIBLE WITH 100%METHANOL? 0 YES [::]NO 0 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP F-�2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 0 91 NONE UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A .0 2 PRESSURE U)3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBFRGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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]S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P G/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? DYES .L] NO - THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRfNTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACIlI 91 TANK ID# El I I o CURRENT LO A NCY FACILITY ID k APPROVED BY NAME PHONE 1!WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY, ' -'p FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY