COMPLIANCE INFO_1985-1992 - Laserfiche WebLink

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STATE OF CALIFORNI WATER RESOURCES CONTR OARD W.• FORM 'B': UNDIMbROUND STORAGE TANK PR AM TANK n�fTANK PERMIT APPLICATION INFORMATION .., COMPLETE A SEPARATE FORM WITH THE FOLLOWING PFORMATION FOR EACH TANK. ' ��lIFO NSP MARK ONLY , WEW 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: C FARM TANK-YES❑ NO ©' 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID# B. MANUFACTURED BY: �� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Z/CZ70 eclat- . � 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. E�jlMOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑"2 LEADED ❑ 3 DIESEL ( '( ❑3 CHEMICAL PRODUCT ❑ 4 OIL E31 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.# C.A.S.#: jx111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF E 7 60UBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON F-] 2 STAINLESS STEEL �3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F' 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP 9 BRONZE El 10 GALVANIZED STEEL [:]95 UNKNOWN 99 OTHER 1 RUBBER LINED El 2 ALKYD LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING C.INTERIOR LINING ❑5 GLASS LINING WfUNLINED L�-j 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES 10 ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP E�t'4FIBERGLASS 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 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) 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. /// P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL 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 . I FFORMAT1 ON TANK PERMANENTLY CLOSED IN PLACE AT TE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO F THIS FORM HAS BEEN CO ETE NDER PENALTY OF PEWORY,OND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLIC M RINTE SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# / �/ / CURRENT LOCAL AGENCY FACILITY ID#? APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER T EXPIRAT16WlFATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIEVR A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ORENT FORMA' HAS BEEN FILED DATA PROCESSING COPY �>