COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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STATE OF CALIFORNibb WATER RESOURCES CONTR OARD :. FORM 'S': UND ROUND STORAGE TANK PROL3'RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C K MARK ONLY F-11 NEW PERMIT ❑ ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE J FACILITY/SITE NAME WHERE TANK IS INSTALLED: �j' ARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: V C Q� C. YEAR INSTALLED t D. TANK CAPACITY IN GALLONS: 00 0 II. TANK 92NTENTS 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 [ZKDIESEL ❑ 3 CHEMICAL PRODUCT F-] 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OFV2,SINGLEWALLED OUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINEDV199 UNKNOWN [:] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT V95 L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:] 5 CATHODIC PROTECTION ❑91 NONE NOWN ❑ 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 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A OU 5 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 A U 91 NONE C.MATERIAL A U 5 ALUMINUM A V,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. S 1 VISUAL CHECK P& 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS V 1p S 6 PRECISION TESTING P S 7 PRESSURETESTING 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 T 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I INERT MATERIAL? [:]YES ❑ NO 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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# L-Li l �{ v2A4VEIKI CURRENT LOCAL AGENCY FACIYU ID# APPROVED BY NAME PHONE#WITH AREA CODE 0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY