COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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STATE OF CALIFORhM WATER RESOURCES CONT BOARD FORM `B': UN R ND #94183D 'RGROUND STORAGE TANK PR RAMa TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. oa MARK ONLY ❑ 1 NEW PERMIT ®3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Lakewoodevron FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: Unknown C. YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 10,000a ons 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 ❑ 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) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# A. Q III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D P4 r A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN JUN 8 19�U SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEL/IRONX❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLADW/FIBER B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-]7 ALUMINUM ❑8 100%METHANOL COMPATIBLE R �ll T/SERVICES MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑2 ALKYD LINING ❑ 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 ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION X❑5 CATHODIC PROTECTION ❑91 NONE 0 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 UU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A @1 SINGLE WALLED A U 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 AO 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 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. P S I VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 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(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY RJURY, Tq T B F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) Q DATE LOCAL AGENCY USE ONLY E JURISDICTION# AGENCY# FACILITY ID# TANK ID# I I ]- 0 1 LL FTT Ll I I Fi-1 AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM'A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY