REMOVAL_1990 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORI WATER RESOURCES CONTBOARD a FORM'S': UNDERGROUND STORAGE TANK PROGRAM o �� TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK, I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [R5CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T K ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED J FACILITY/SITE NAME WHERE TANK IS INSTALLED: I 1 J C� j (_ FARM TANK - YE5 ❑ NO s ' n I. TANK 'DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY '4 cn FCYRS TANK ID # B. MANUFACTURED BY:'%INSTALLED D. TANK CAPACITY IN GALLONS: L II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE 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 AWATION GAS ❑ 5 HAZARDOUS TR 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF CAS #: HAZARDOUS SUBSTANCE STORED & C.A.S. # TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4STEELCLAD WIFIBERGLASSREINFORCED PLASTIC ❑ 8100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOLIC LINING *K95 UNKNOWN F-199 OTHER 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 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 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVCj A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U B 100% METHANOL COMPATIBLE FRP 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. LPP 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE 60 S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (M ) 2. ESTIMATED QUANTITY Of T3. WAS TANK FILLED WITH �? SUBSTANCE REMAINING IN /� INERT MATERIAL? ❑YES NO Ez !I ( ` GALLONS THIS FORM HAS BEEN COMPLETED UNDER PP-E-NAALL/TY' OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICAi ! (PL/ // D ATLIR LOCAL AGENCY USE ONLY COUNTY # A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER CURRENT LOCAL AGENCY FACILITY ID # ��I� I4 � SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS B. TANK ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN F-11 RUBBER LINED 2 ALKYD LINING El3 EPDXY LINING C. INTERIOR F-]5 GLASS LINING F-]6 UNLINED LINING F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL] ❑ YES -] NO D. CdRROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4STEELCLAD WIFIBERGLASSREINFORCED PLASTIC ❑ 8100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOLIC LINING *K95 UNKNOWN F-199 OTHER 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 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 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVCj A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WIFRP A U B 100% METHANOL COMPATIBLE FRP 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. LPP 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE 60 S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (M ) 2. ESTIMATED QUANTITY Of T3. WAS TANK FILLED WITH �? SUBSTANCE REMAINING IN /� INERT MATERIAL? ❑YES NO Ez !I ( ` GALLONS THIS FORM HAS BEEN COMPLETED UNDER PP-E-NAALL/TY' OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICAi ! (PL/ // D ATLIR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY 1! FACILITY ID # 3 lJ TANK ID # Fn 6 CURRENT LOCAL AGENCY FACILITY ID # ��I� I4 � APPROVED BY NAME laIaK0 /7F PHONE # WITH AREA CODE PERMIT PERMIT APPROVAL DATE CHECK # PERMIT AMOUNT I SURCHARGE AMT EXPIRATION DATE FEE CODE RECEIPT # 1 BY: FORM a (6-29-13B) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM `A', UNLESS AMAEN7 FORMA' HAS BEEN FILED DATA PROCESSING COPY