BILLING 1985-1998 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN14 WATER RESOURCES CONTROWARD FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING.INFORMATION FOR EACH TANK. MARK ONLY '-❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO T U ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT 6 TEMPORARY TANK CLOSURE j„$Ep ❑ ©'ll TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �/;7_'i /T 1 4 GJ ARM TANK- YES D NO FV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY G, ) �3 U O A OWNERS TANK ION _ LD C B. MANUFACTURED BY: C.YEAR INSTALLED -17-.7- ' D. TANK CAPACITY IN GALLONS: j �) II. TANK,CiONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1).IS NOT MARKED,COMPLETE ITEM D. A MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑I OIL �✓ 1 PRODUCT ❑ A 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 HAZARDOUS SUBSTANCE STORED 8 C.A.S.Y C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C,i D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EATEROR LINER 95 UNKNOWN SYSTEM. ❑2SINGLE WALLED ❑I SECONOARYCONTAMMEM 99 OTHER B ❑ 1 ST�� ❑2 STNNLESSSTEEL ❑3 FIBERGLASS ❑N STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MANTERIAL. ❑" ❑6 POLYVWYLCHLORDE ❑ 7 ALUMINUM ❑B 1901AMETHANOL COMPATIBLE FRP 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I MUM LINED ❑2 ALM LINING ❑3 EPDXY LINING ❑N PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN S:YONGMATLT9ALCOIJPATIBLEMTHI00%METKq&7 ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POLYEFN ENEWRAP ❑2 TM OR ASPHALT ❑3 VINYL WRAP ❑N FIBERGLASS REINFORCED PLASTIC . PROTECTION_ ❑5 CATHODO pROTECTON ❑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 U 2 PRESSURE A 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEFL A U 3 POLYVINYL CHLORIDE(PVC) A U 9 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FOP A U 8 IDD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. 6 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 6 A ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P E 6 PRECISION TESTING P 6 7 PRESSURE TESTING P 8 91 NONE P 6 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATE1:1111 1 ST USF:(MO/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS IN ERT MATERIAL? YES ONO 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 COUNTY Y JURISDICTION Y AGENCY Y = FACILITY ID Y TANK ID Y _ /PIL D U � CURRENT LOCAL AGENCY FACILITY ID/ ' APPROVED BY NAME PHONE 1 WITH AREA CODE PERMITNUMBER - PERMIT A"ROVALDATE PERMIT EXPIRATION DATE y CHECK PERMIT AMOUNT � U ✓ `7 RCHARGE AMT. FEE CODE ,EIPT 1 i,,� FORM B(6-29.0x) THIS FORM MUST BE ACCOMPANIED BYA FACILITYJSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED