BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOAA WATER RESOURCES COOL BOARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK I''.;�.�;:.:.:.� � COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT E[ NGE OF INFORMATION ❑ 7 PERMANENTLY CLO K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: uS s .Z, FARM TANK-YES❑ NO C I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID I B. MANUFACTURED BY: C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: II. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ / OIL PRODUCT E] 4 GASAHOL E] 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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 6 C.A.S.N C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A.TYPE OF ❑ 1 DOUBLE WAILED ❑ 7 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNowx SYSTEM Er2 SINGLE WAILED ❑ 1 SECONDARYCONTAINVENT ❑ N OTHER I STEIFUIRON ❑ 2 STA1NLfSS STEEL ❑3 FIBERGLASS ❑ 1 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC e.TANK ❑ MATERIAL 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOLCOMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [].95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNFD ❑1 LINING F-13 EPDXY LINING ❑1 PHENOLIC LINING G INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWFNP ❑ 2 TAA OR ASPHALT ❑3 VI WRAP Fl1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHOOICPAOTECTION ❑ 91 NOW %UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION__ CIRCLE A IFABOVE GROUND, U IFUNDERGROUND,BOTH IFAPPLICAB E A. SYSTEM TYPE A 1'SUCTI9 A U ?PRESSURE A U 3 GRAVITY A U 9 A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U NO E ) A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERLAL A U 5 ALUMINUM A U S CONCRETE A U I STEEL CLAD W/FRP A U S 1009E 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. P 11 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P i 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P • S PRECISION TESTING P S 7 PRESSURE TESTING 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/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION I AGENCY IFACILITY ID I TANK IO I EIZ I I El 0- 1 1 1 //}} I o F/ I � 1 �-7 1 L-) I J CURRENT LOCAL AGENCY FACILITY ID 0 APPROVED BY NAME PHONE I WITH AREA CODE A<`cUS '7 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE `^ CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT II pr; mou R rrr.9a w THIS F[TRM WIRY RF 1rmuoii,umn or i rarR rTviviTe►Der I^av-m- Cf)13&A -A 0