COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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-7 1 ^ 1 G Vr VJWLL.IvVRIr WAItFi NI VAIiU /y �F FORM `B': UND GROUND STORAGE TANK PR RAM T TANK PERMIT APPLICATION INFORMATION AN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 XW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV FACILITY/SITE NAME WHERE TANK IS INSTALLED: t, J`> FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 A. OWNERS TANK ID# B. MANUFACTURED BY: h� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 145),®w 11. TANK C .NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CQ A. EB 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. El1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT F-14 OIL riPRODUCT ❑ 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.# Al C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL [_ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING C 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 �&THODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABAE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION AW U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION V-1 SINGLE WALLED A 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 U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 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 SED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANF,ILLED WITH SUBSTANCE REMAININ INE M IAL? ❑YES [:] NO �✓ GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) _T DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID#[3 /TANK ID# ( ® D .! L? J.? CURRENT LOCAkGENCY FACILITY ID# kAppR VE !"AME PHONE#WITH AREA CODE PERMIT NUMBER PE 1 APP OV L DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARM-AMT1 FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANMOwrOY A FACILITY/SITE APPLICATION, FORM 'A',UNLES RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY