SITE HISTORY - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORfvrrw WATER RESOURCES CONTMt-DOARD '•".. FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION � o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z i CJ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREF,:�:J�NK REMOVE _ 1 N FACILITY/SITE NAME WHERE TANK IS INSTALLED: �N �S (. FARM TANK-YES NO F1 ji 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK IDN B. MANUFACTURED BY: CA7 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 M6FiVEHICLE FUEL ❑ 2 PETROLEUM B. r ; C, 1:11 UNLEADED ❑2 LEADED E]3 DIESEL ❑ 3 CHEMICAL PRODUCT F-] 4 OIL F-11 P DUCT' ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2,Y ASTk l ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR V �11CLE FUEL,ENT R NAM F HAZARDOUS SU SIayge STOREIA C.A.S f/"� C.A S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED MgTH EXTERIOR LINER ❑95 UNKNOWN SYSTEM _ ❑ 2 51 WAllED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 ST l ❑ 2 STAINIESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8108%METHANOL COMPAT18LE FRP MATERIAL M,g �. 1 �.� ' (1 (YAM)ED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR �. +RUBBER.UNED 2 ALKYO LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNUNED ❑95 UNKNOWN ❑ ISI I[IGMATERML COMPATIBLE WITH IDR,METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 PO�.YET ,E�RAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ED 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 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 STAINL/ESSSTEEI,I A U 3 QLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL / A U 5ALUMINUI� A U 6CONgRETE A U 1STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP I/ A U 9 GALVANJ3ED STEEL A U 95 UYNOWN 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRIN &SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID M TANK ID M F= I = 0 CURRENT LOCAL AGENCY FACILITY ID O APPROVED BY NAME r E N WITH AREA CODE I lk PERMTT NUMBER PERMIT APPROVAL DATE PERMtr E% RATION OAjy CHECK PERMIT AMOUNT CHARGE AMT. FEE CODE 1 PTO BY: .w/ FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIED ST A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A C�TARENT FORMA' HAS BEEN FILED