COMPLIANCE INFO_1986-1994 - Laserfiche WebLink

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..,,...,.-.....-.-.•rn. u,..;.+.•� r7..:. ::, 5 .S, ..,:.: .:: :; �'+`r. ,:y�..k ew a;,� I"�+ � s. m..- :ate+-a�:x r sr" �ua. ,, r STATE OF CALIFOFWAh WATER RESOURCES CO OARD FORM `B': 1.119MROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE 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 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ' a FACILITY/SITE NAME WHERE TANK IS INSTALLED: a7 o l W r a-rc- 1 . FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # (,,- K B. MANUFACTURED BY: u., C. YEAR INSTALLED / 1?p1 D. TANK CAPACITY IN GALLONS: /15 ®DO 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 ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL B. U2 -1 -"PRODUCT C.1 UNLEADED 2 LEADED 3 DIESEL ❑ 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. If C.A.S. #: xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 5d 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER F-]1 STEEL/IRON 2 STAINLESS STEEL ® 3 FIBERGLASS 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 A 1 RUBBER LINED 2 ALKYD LINING F-13 EPDXY LINING F--]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED U 6 CONCRETE 9 95 UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO 99 OTHER D. CORROSION ❑ I 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 A U 1 SUCTION A Q 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 0 4 FIBERGLASS PIPE 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. m P S 1 VISUAL CHECK 10 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P�6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN POS 99 OTHER -%L VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY IID # SUBSTANCE REMAINING IN INERT MATERIAL? 1:1YES ❑ NO GALLONS ` % 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) -T DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY IID # TANK IDD # ` % / CURRENT LOCAL AGENCY FACILITY ID # APP OV B NAME PHONE # WITH AREA CODE ct, R"'elk PERMIT NUMBER PERMIT APPROVAL dATE PERMIT EXPIRATION DATE 7P/ ?K CHECK # PERMIT AMOUNTSURCHAR E AMT FEE CODE RECEIPT # BY: FORM 8 (3-7-88) THIS FORM MUST BE ACCOMPANIEO"EY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A ZURRENT FORMA' HAS BEEN FILED U `) DATA PROCESSING COPY