SITE INFORMATION AND CORRESPONDENCE_FILE 2

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ••';..:, FORM V: UNDERGROUND STORAGE TANK PROGRAM VL TANK C-1-11TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWINGjPFDRMATION FOR EACH TANK. z t0 MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LO NK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [:]8 TANK REMOVED CA) FACILITY/SITE NAME WHERE TANK 18 INSTALLED: 7_ ? /./ FARM TANK-YES❑ NO N (. .TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: U IV C.YEAR INSTALLED 4q6jrD. TANK CAPACITY IN GALLONS: Q 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,POMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMWI C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT 4 OIL RODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.&D i A.TYPE OF 1:1AuBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 AWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK f F-1 MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM r-18 1009E METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALM LINING ❑3 EPDXY LINING R�UNKNOWN HENOLIC UNING LINING 5 GLASS LINING ❑6 UNLINED ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [-]NO L IA 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT VINYL WRAP ❑4 FIBERGLAGS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE R95UNKNOWN ❑99 OTHER IV. PIPING INFORMA ION 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 An 95 UNKNOWN A U 99 OTHER A U 1 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 W)6,CONCRETE A U 7 STEEL CLAD W/FRP A U S 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. i 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 6 P 8 6 PRECISION TESTINGM 07 PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH . SUBSTANCE REMAINING IN GALLONB INERT MATERIAL? ElYES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 0 JURISDICTION# AGENCY# FACILITY ID# TANK ID# 101011 lI71f] 1010 7 [PERMIT RENT LOCAVAGENCY FACILITY 1 APPROVED BY NAME PHONE#WITH AREA CODE NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATECK# PERMIT AMOUNT +URCHARG!AMT. FEE CODE `EIPT# BY; i o W FORM B(6-29-86) THIS FORH MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED _DATA PROCESSING COPY _