Laserfiche WebLink
STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD , <br /> FORM Be UNDERGROUND STORAGE TANK PROGRAM :. <br /> TANK TANK PERMIT APPLICATION INFORMATION " <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 ORMATION FOR EACH TANK ti z <br /> MARK ONLY `•❑1 NEW PERMIT p 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION p 7 PERMANENTLY <br /> ONE ITEM p 2 INTERIM PERMITp 1 AMENDED PERMIT p 6 TEMPORARY TANK CLOSURE p 8 TANK Z, <br /> W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: �y(aG FARM TANK-YES p NO N <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> CO <br /> A.-OWNERS TANK ID f / B. MANUFACTURED BY- co <br /> C.YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: 6 <br /> -11. TAN NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A l MOTOR VEHICLE FUEL p 2 PETROLEUM C. p t UNLEADED p 2 LEADED 3 DIESEL <br /> M.3 CHEMICAL PRODUCT p 1 OIL 1 PRmw p 1 GASAHOL p 5 JET FUEL p 6 AVIATION GAS <br /> p 6 HAZARDOUS p 80 EMPTY p 96 UNKNOWN p 2 WASTE p 7 METHANOL p 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 6 CAS.N CA.S.N: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.A D <br /> A TYPE OF ❑I DOUG WAILED p 3 SINGLE WALLS WITH DMOR UNER p 95 UNrJCHOWN <br /> SYSTEM p 2 SINOLEINWO .- p 4 MMNDWCONTAINIVff p 99 OTHER <br /> I <br /> ' p 1 STEEUIRON p 2 STAINLESS SM p 3 IBM= p/STEEL CLAD W/FIWC ASS REINFORCEDPLASM <br /> L TANK <br /> p 5 oONCRETE p 6 POLYVWL DUFCOE p T AUJUINN,t p 810011 UETWIN X CDupAToH Rip <br /> p 9 BRONZE p iG GAWA)ZED STEB. p 95 mom p 99 OTHER <br /> C.I�lGR o 1 F11BBERL1E F 2 ALKYD Ll)8NG o 3&OXYLW p,PIENOUCLBNNG <br /> LINING p S GLASSum; p 8 t1NUN® p 95 uNw" <br /> ❑ISLN.NDMATER CO1IpAT9 EWr,►„DD,111ETHANDL, p YES p NO p 99 OTHER <br /> D.CORROSION ❑t POLYEMEE WRAP . p 2 TM OR AVMT p 3 vlNn WRAP p 4 FIBERGLASS FEBNFORM PLASTIC - <br /> PROT 11 .p 5 CATHOOICFWMCTION p 81 NONE ❑96 ❑19 OTHER <br /> I ' IV. PIPING INFORMATION- -CIRCLE-A IF ABOVE GROUND,U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> 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 <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CNiORIOE(PVC) A U N FIBERGLASS PIPE A U 91 NONE <br /> G MATERIAL A u s ALUMINUM A U e CONCRETE A U 7 STEEL CLAD W/FRP A u b 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL # U 96 UNKNOWN A U W OTHER- <br /> I <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR s FOR SECPNDARY,A-PRIMARY LEAK DETECTION SYSTEMMUSTBE-CIRCLED:--- <br /> r s 1 VISUAL CHECK P a 2 INVENTORY REcaNCILIATION P s i VADOSE WEU.S P B 4 E ECTRONNC MOWTOR P.s.S GROUNDWATER MONITORING WELLS <br /> r s 6 PRECISION TESTING r 8 7 PRESSURE TES I NO P B 91 NONE P B 95 UNKNOWN ► f 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR)- T2.ESTIMATED OUANTITY OF-- &WAS TANK FILLED WITH <br /> -- <br /> . -SUMANOE REMAINING IN GA RA" INERT MATuml? [—]YES pNO <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGF,IS TRUE AND-CORRECr— <br /> APPLICANTS NAME(PRINTED a SIGNATURE) DATE <br /> i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY f * .JURISDICTION f AGENCY! FACILITY ID! TANK ID f <br /> 3 `� 6 3� F7 <br /> CURRENT LOCAL AGENCY FACILITY ID 9 APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> • g iZ <br /> CHECK N PERMIT AMOUNT IRCHARGE AMT. FEE CODE 'EIPT N Br: � <br /> FORM B(6.29-mi THIS FORM MUST BE ACCOMPANIED BY A FACIL1T11/SITE APPLICATION, FO P M 'A'.IlNI Fcc A cljvoe•n eneu­ -iA c e—u•Ir en <br />