SITE HISTORY - Laserfiche WebLink

Home Browse Search

f. 47tj:-t�v..-o....-r.c—�nv�.hT�,S...:�'vis..��+a.� �: �`�IT�iS'R•:''��i;ts'a €>i^�;'.�-'ify�-'S,="��^"'=f�'�7��'J W?T- ��.Ri Vii:.�.. STATE OF CALIFORK.Al WATER RESOURCES CONT QBOARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION i COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 MATION FOR EACH TANK. - M hh !! MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS DT C 4 j ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: W !rZ FARM TANK-YES❑ NO EE7jv Cr j I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID 4 B. MANUFACTURED BY: j C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: pZ) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 OR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL IE213,CHEMICAL PRODUCT 4 OIL 1 PRODUCT F-14 GASAHOL 5 JET FU 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N � �(/��- CAS,N: I - III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,3 D ' A TYPE OF ❑ 1 LE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SING WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER € 1 5TEELPRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑8 100%mEIHANOLCOMPATIBLE FRP { MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑ 99 OTHER '. i ❑ i RUSBERUNED ❑2 A KING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASSUNINGUNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 190%METHANOL? ❑YES ❑NO ❑99 OTHER I D. CORROSION ❑ I POLYETHLENE WRAP B;I'NOME TA ASPHALT 3 VINYL WRAP 4 FIBERGLASS REiNFORCEO PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑95 UNKNOWN ❑ 99 OTHER i i 3 IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ! A. SYSTEM TYPE A U i SUCTION - A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE . . C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 : 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 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 OUANTITf OF T3. WAS TANK FILLED WITHSUBSTANCE REMAINING IN INERT MATERIAL? YE5GALLO 4 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY ' COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# / 3 b a / i CURRENT LOCAL AGENCY FACILITY ID>t APPROVED BY NAME PHONE N WITH AREA CODE /(JG �tJ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE l CHECK R PERMIT AMOUNT SURCHARGE AMT. FES CODE RECEIPT* BY: I FORM 8(6.29-88) THIS FORM MUST BE ACCOMPANIED St-fACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY