COMPLIANCE INFO_1986-2006 - Laserfiche WebLink

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STATE OF CALIFORNI WATER RESOURCES CONTRO ARD UN AROUND STORAGE TANK PRO AM FORM B . U =� o TANKTANK PERMIT APPLICATION INFORMATION C" - CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑66 TEMPORARY TANK CLOSURE E]8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: s �G�J� L FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: c" 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 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C• 1 UNLEADED ❑ 2 LEADED3 DIESEL ❑ 1.�1 3 CHEMICAL PRODUCT ❑ 4 OIL "PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ION 4GAS ❑ 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.# A44 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑�4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM IrJ 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL ❑ !YKNOWN ❑99 OTHER ❑ 1 RUBBER LINEDLKYD LINING DOXY LINING ❑4 PHENOLIC LINING C. INTERIOR f/ LINING ❑ 5 GLASS LINING 6 UNLINED" ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMP IBLE ITH 100%METHANOL? efrYES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 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 U 1 SUCTION A tl.,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 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(PVC) A U4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A08 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 I(JVENTORY RECONCILIATION P S 3 VADOSE WELL P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S I PRECISION TESTING P S 7'PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST ffD(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH S1tlBS�f E REMAINING IN GALLONS IN T ATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNO LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [1E I I I I El I I loloTPN� ` [ olo lo 171 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY N PHONE#WITH AREA CODE Lolji t4-1- PERMIT NUMBER PERMIT APPFoVALqhTE P MITE PIRA ION DATE CHECK# PERMIT AMOUNT SURCHARGE AMIf f FEE CODE RECEIPT# BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPAh BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSMRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY