BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI0k WATER RESOURCES CONTRO' IOARD FORM BI: UND�WGROUND STORAGE TANK PRO`G'RAM TANKTANK PERMIT APPLICATION INFORMATION Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLYCLO ANK ONE ITEM ❑ 2INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE G 8 TANK REMOVED b w FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (� f�LO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK IDR B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: lj�-Q D d II. TANK S2NTENTS IF(AA),IS MARKED,COMPLETE IT C.IF( 7),IS NOT MARKED,C94PLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑T METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A.TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH E%TERIOR LINER ❑95 UNKNOWN SYSTEM 2 SI WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑T UMINUM ❑ 8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL W95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNDO ❑2 ALKYD LINING ❑ 3 EPO%YLINING4PENOUC LINING C. INTERIOR 5 GLASS LINING 6 UNLINED �l 95 UNKNOWN LINING F7 ❑ Ly ❑ IS LINING MATERIAL COMPATIBLE WITH In METHANOL? ❑YES ❑ NO ❑99 OTHER 0.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT3 V WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM' A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U MOTHER B.CONSTRUCTION A 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 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 CONCRETE A U T STEEL CLAD W/FRP A U 8100%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. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION8 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P 8 T PRESSURE TESTING 14, 8 91 NONE P 8 %UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENT CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO// 2. ESTIMATED QUANTITY OF &WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [-] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY R FACILITY ID R TANK ID R 10101 Z-1 3 y C91 v / CURRENT LOCAL AGENCY FACIIATY ID# APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L ory E A Z e'r CHECK# PERMIT AMOUNT SURCHARGE AMT FEE CODE RECEIPT# FORM B(e-29-88) THIS FORM MUST BE ACCOMPANWI7%TA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CMRRENT FORMA' HAS BEEN FILED (\J\ DATA PROCESSING COPY