BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIAja WATER RESOURCES CONTROL rOARD FORM V: UNDE ROUND STORAGE TANK PRO AM ' 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 CLOSED TANK I ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED p 6 TEMPORARY TANK CLOSURE GI a TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: X X d /1 91S 7-613 (- FARM TANK-YES❑ NO ® G 10 i 1. TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERSTANKID# 3p B. MANUFACTURED BY: Wens Ow1rH a/ Q/XeS C.YEAR INSTALLED / 6 6 D. TANK CAPACITY IN GALLONS: /0, 0 o O A IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. C n m A. ® 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLSWD ®'2 LEADED ❑3 DIESEL —4 ❑3 CHEMICAL PRODUCT ❑ 4 OIL Ea1 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 HAZARDOUS SUBSTANCE STORED&C.A.S.It CA.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 351NGLEWALIEDWRH EXTERIOR LINER ❑95 UNKNOWN A TYPE OF 1DOUBLE WALLED ❑ SYSTEM ❑2 SINGLE WALED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLryWRCHLORIDE ❑7 ALUMINUM F-16100%ME7HANOLCOMPATIBIE FRP MATERIAL ❑9 BRONZE IO GALVANIZED STEEL ❑95 UNKNOWN ❑ W OTHER F-] 1 RUBBER LINED ❑ 2 ALKYD UNING F—] 3 EPDXY UNING F-14 PHENOLIC UNING C. INTERIOR LINING ❑5 GUSSUMNG �6 UNUNED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? [:]YES [:] NO 99 OTHER D. CORROSION ❑1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3VINYL 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 SUCTIONA 2 PRESSURE A 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A O2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A(9 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U P 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. P8 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS�S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 5 7 PRESSURETESTING 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 III 2.ESTIMATED OUANTITY OF 3.WAS TANK 61LLEO WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E:]YES ❑ NO THIS FORM HAS BEEN COMPLEErED UNDER PENALTY OF PERJURY,AND i 0 T BESTQF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAMESIGNATURE) DATE YFR-U .ANALYST LOCAL AGENCY USE ONLY COUNTY# II( JURISDICTION# AGENCY# FACILITY ID# TANK ID# m -� CURRENT LOCAL AGENCY FACILITY IDk APPROVED BY NAME PHONE WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE '., CHECK III PERMIT AMOUNT SURCHARGEARIT. FEE CODE RECEIPT# BY: FORMB(3-7AB) THIS FORM MUST BE ACCOMP BY AFACBRY/BREmwucATION, FORM`A',UNLE URRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY