BILLING - Laserfiche WebLink

Home Browse Search

,. STATE OF CA4.IFOR WATER.RESOURCES CON "IOARD FORM 'B': UND&ROUND STORAGE TANK PRI��RAM TANK C/ TANK PERMIT APPLICATION INF RMATION ° ti COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 RMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHAN INFORMATION �7 PERMANENTLY CLOSEDT K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT S_ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FAIRGRO S INDUSTRIAL F FARM TANK-YES❑ NO 0 Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co A. OWNERS TANK ID# UNKNOWN B. MANUFACTURED BY: UNKNOWN w C.VFAR INSTALLED UNKNOWN D. TANK CAPACITY IN GALLONS: lO,OOO 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.W(A.1),IS NOT MARKED,COMPLETE ITE B C. 1 UNLEADED 2 LEADE ❑ 3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑3 CHEMICAL PRODUCT ❑ 4 OIL ® 1 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 C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D EF-1 OUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ®95 UNKNOWN ❑99 OTHER SINGLE WALLED ❑4 SECONDARY CONTAINMENT , TEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGIASSREINFORCED Pl C.7 . ONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOLCOMPATIBLEFAP �Z RONZE ❑A GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER ❑ RUBBER UNEO ❑2 ALKYDUNING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING �'-ZI kr�� C.INTERIOR 95 UNKNOWN �S � LINING ❑ 5 GLASS LINING ❑6 UNLINED m ❑IS LINING MATERIAL COMPATIBLE WITH III%METHANOL? ❑YES ❑ NO ❑99 OTHER M CORROSION ❑I POLYETHLENEWRAP ❑ 2TAR OR ASPHALT ❑ 3VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC S � PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 0 95 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 U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 A 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 C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(995 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 8 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF n SUBSTANCE REMAINING IN O GALLONS INERT MATERIAL? []YES [k' NO UNKNOWN THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. AP ICANT'SNAME INTED&SIGNATURE) DATE 10/13/89 SYDNEY LEVIN LOCAL AGEN US ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# a o �= CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE k WITH AREA CODE eG/,L PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHEOKk PERMRAMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY, FORM B(6-29-fie) THIS FORM MUST BE ACCOMPANI . A FAC I DATA TION, NOGRM' UNLESS A,_ RENT FORM'A' HAS BEEN FILED