BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

I , I A 1 t Vr %,:ALII-*Nj& WATER RESOURCES T�gOARD FORM 'B': LAND GROUND STORAGE TA PROGRAM g TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - o MARK ONLY ❑ 1 ;NEWPERIMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONONE ITEM ❑2 RMIT ❑ 7PE NTLY CLOSE�3A11K ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE INSTALLED: SSS' _ 1y I. TANK DESCRIPTION COMPILE ITEM ETE ALL S-IF UNKNOWN-MTs L�74-4 FARM TANK-YES❑ NO SO SPECIFY •D A. OWNEHS TANK ID N �4-. B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: CJ II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D, µ A_ ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ ip6DUCT ❑4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑ 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 A C.A.S.N C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,8 D [0. YPE OF I UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN YSTEM 2 GLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC ANK ❑ 5 CONCflETE ❑ATERIAL ❑ 6 POLYVINYLCHLORIDE 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑q YPKUC LINING LINING ❑5 GLASS LINING ❑6 UNLINED WN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO r 990THER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑ UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUNO,BOTHIF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAViTV B. CONSTRUCTION A U 1 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 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 STEELCLAD W/FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U B 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 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 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 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTIIV OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH 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. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY r COUNTY NJURISDICTION N AGENCY N FACILITY ID M �.J l.� U I / TANK ID M / (L/ LE.Aml LOCAL AGENCY FAC L' '0* APPROVED BY NAME PHONE N WITH AREA CODE Lt AIT MBER PERMIT APPROVAL DATE PERYIT E%PIRATION DATE PERMITAMOUNT SURCHARGE AMT. FEE CODE FORM B(6-29-BS) THIS FORM MUST BE ACCOMPANIED BY A ACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILE DATA PROCESSING COPY