Laserfiche WebLink
•6-wSUTE OF CALIF6ANIA WATER RESOURCES(�,4TROL BOARD ''••'••'''FORM `B': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE o. <br /> A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> ❑i NEW PERMIT 3 RENEWAL PERMIT E]5 CHANGE OF INFORMATION El 7 P NENTLY CLOSED TANK <br /> MARK ONLY <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED 6 <br /> FARM TANK <br /> YES LiNO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> A444, �Aed <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK IDM B. MANUFACTURED BY: <br /> D. TANK CAPACITY IN GALLONS. <br /> C.YEAR INSTALLED <br /> :-r 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED E]3 DIESEL <br /> 4 OIL i PRODUCT ❑4 GASAHOL ❑5 JET FUEL [_]6 AVIATION GAS <br /> 3 CHEMICAL PRODUCT <br /> 95 UNKNOWN El 2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 5 HAZARDOUS E]60 EMPTY <br /> El <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ` A CA.S.N: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N <br /> y III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,c,a o <br /> WALLED 3 SINGLE WALLED WITH E10ERIOR LINER 95 UNKNO" <br /> A.TYPE Of 4 SECONDARY CONTAINMENT 99 OTHER <br /> SYSTEM R2 SINGLE WALLED <br /> y SIEEUIMN E]2 STAINLESSUEEL M 3 FIBERGLASS 0 4 STEEL CLAD W/FIBER(ILASSREOJFORCEDPLASTIC <br /> S.TANK5 CONCRETE F]6 POLYVINYL CHLORIDE 7 ALUMINUM Ele 100%METHANOL COMPATIBLE RIP <br /> MATERIAL <br /> 09 BRONZE El <br /> _ 10 GALVANIZED STEEL 95 UNKNOWN 099 OTHER <br /> r [-] 1 RUBBER LINED 2 LINING �3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 5 a UNLINED �95 1�LINING [ISUMNGMATERIALCOMPATe�EYATH100%METHANOL? YES []NO <br /> ..r AROR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> D.CORROSION El1 POLYETHLENE WRAP <br /> PROTECTION [D 5 CATHODIC PROTECTION 91 NONE [EJ 95 UNKNOWN [�99 OTHER <br /> u IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A 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 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 /> wr A U I.STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A u ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE FRP <br /> A GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> y V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> a P S 1 VISUAL CHECK P s 2 INVENTORY RECONCILIATION P s 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P a s GROUND 99 OTHER WATER MONITORING WELLS <br /> 91 NONE P S 95 UNKNOWN <br /> P !{ 6 PRECISION TESTING P S 7 PRESSURE TESTING <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.W TANK FILLED WITH <br /> 1.ESTIMATED DAT LAST USED(MO/YR) 2.ESTIMAT O QUANTITY OF MATERIAL? E]YES NO <br /> I- SU S REMAINING IN GALLONS <br /> y THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) <br /> v <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION M AQENCY S FACILITY IDA TANK ID N <br /> LO R� 1-31 <br /> [111 <br /> CUR T LOCAL AOCY FACILITY ID• APPA VE�NAj! � <br /> PHONE t WITH AREA COD! <br /> l/S-1 11, <br /> sp <br /> .� PERMIT NUMBER will PERMIT APPROVAL DATE PERMR EXPIRATION DATE <br /> CHECK t PERMIT AMOUNT SURCHARGE AMR. <br /> FEE CODE RECEIPT t BY: <br /> ........Q•nnnuemcn of A iACILiTY/SITE APPLICATION. FORM'A',UNLESS A CURRENT fORM'A' HAS BEEN FILED <br />