COMPLIANCE INFO_1987-1995 - Laserfiche WebLink

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STATS OF CALIFORNI> WATER RESOURCES CONTRO ARD FORM ` ': UNDERGROUND STORAGE TANK PROLI Gk TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. '" 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK I MARK ONLY ❑ ❑ � ❑ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSUREd❑8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: Aiuo r_pru{L( oqo FARM TANK-YES❑ NO N WTI nn,, IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-- SO SPECIFY ,'jam 00 d A. OWNERS TANK ID# B. MANUFACTURED BY: X5;?7CF"j C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: S S Q 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 LEADED ❑3 DIESEL F-] 3 CHEMICAL PRODUCT © 4 OIL ❑ 1 PRODUCT ❑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) i 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 A.TYPE OF © 1 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [:j 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I ❑1 STEEL/IRON ❑2 STAINLESS STEEL © 3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ,, jCONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP ! MATERIAL d� ❑ ❑ ❑ ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED E:]2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING - LINING ❑5 GLASS LINING ®6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP a 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 9 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH_ A JU 91 NONE U UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CFL I (PVC) k' i iFI$ GLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADS A r ' '100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHERS' V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRI , 'LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSO S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE 10.1 95 UNKNO P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN t,fW46E 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH W/A SUBSTANCE REMAINING IN .- .. ' � GALLONS INERT MATERIAL?WA ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UN ER PEN F P J Y,AND TO sTHE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATOR DATE PAv It, G, WI I.TbIJ LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT L A AGENCY FACILITY�D APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER (/ PERMIT APPROVAL DATE PERMIT E ATIO ATE c?/ _i' CHECK# PERMIT AMOUNT URCHARGE AMT. FEE CODE IPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY