COMPLIANCE INFO_1995-2011 - Laserfiche WebLink

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STATE OF CALIFORN WATER RESOURCES CONTR OARD :. FORM 'B': UNDERGROUND STORAGE TANK PRO RAM �o { TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFO ATION FOR EACH TANK. i® MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2r5--CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLQS ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# '-2-777` B. MANUFACTURED BY: C. YEAR INSTALLED 9 D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MAR D,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 P LEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL &�R O T ❑4 GASAHOL ❑❑ 51J 5 ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINERNKNOWN SYSTEM ❑ 2 SINGL ALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS F__]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-]5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING E]4 PHENOLI INING LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER 1)17 D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT [E::]E;5-UNKNOWN VINY AP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION [:] 91 NONE ❑ 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 9 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 -15 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. J 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 I 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 /YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? El 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(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID#DO� EJ _31� 3 7 CURRENT LOCAL AGEN Y FACILITYID# APPROVE71_ZA� PHONE#WITH AREA CODE 3y & PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI FACILITY/SITE APPLICATION, FORM`A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY