BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN& WATER RESOURCES CONTBOARD FORM `B': UN GROUND STORAGE TANK PR RAM o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 AEW PERMIT F-13 RENEWAL PERMIT C NGE OF INFORMATION ❑7 PERMANENTLY CLOSEQZANK- ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 70FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Z A. OWNERS TANK 10 B. MANUFACTURED BY: C. YEAR INSTALLED 0, TANK CAPACITY IN GALLONS: /c o II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. °11 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C, 1:11 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS [:j5 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 HAZARDOUS SUBSTANCE STORED&C.A.S.# VIA C.A.S.#: xIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM U R- NGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER EEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-] 1 RUBBER LINED El ALKYD LINING ❑ 3 EPDXY LINING El PHENOLIC LINING C. INTERIOR ❑ LINING 5 GLASS LINING - LINED 1:195 UNKNOWN ❑ 1S LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP R OR ASPHALT ❑ 3 VINYL WRAP ❑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 1 SUCTION A Uj PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 U 5 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 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GRL7UND WATER MONITORING WELLS P PRECISION TESTING.. P 5 7 PRESSURE TESTING P 5 91 NONE P 5 95 UNKNOWN P 5 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USE (MOIYR) 2- ESTIMATED OUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES [:] NO THIS FORM HAS 8E N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY FNUMBER JURISDICTION# AGENCY# FACILITY ID# TANK ID# [m I 1 1 :1 1 1 i -1 1 o 16 F/ Fo-T� I o li I AGENCY FACILITY ID# APPROVED BY/NNA�M , E M WITH AREA CODE (/ T PERMIT APPR YAL DATE ERMlT XPIRATION TE PERMIT AMOUNT SURCHARGE AM . FEf CODERECEIPT# BY:. FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI FACILITYISITE APPLICATION, FORM 'A',UNLESS A NT FORMA' HAS BEEN FILED DATA PROCESSING COPY