COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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STATE OF CALIFORNI WATER RESOURCES CONTR OARD st"`�o: ref FORM `B': UNDL�GROUND STORAGE TANK PROI�I`RAM `----- m �o TANK / TANK PERMIT APPLICATION INFORMATION ` Z"" A SEPARATE FORM WITH THE FOLLOWING IN,FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO NK 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0� FARM TANK-YES❑ NO Icy I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOS ECIFY 157;19 � A. OWNERS TANK ID# 41 1 B. MANUFACTURED BY: vl< co C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ( 000 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 ❑ ETROLEUM �kl C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL -13 CHEMICAL PRODUCT 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET EL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# u,L t C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OFC WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑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 ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 HENOUC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑6 UNLINED VNKNOWN ISLININGMATERIALCOMPATIBLEWITH100%METHANOL? YES NOER D.CORROSION ❑1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT V95 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 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U95 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 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 (J llVI. 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? E]YES E] 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# ® 1 � 6 p C? :[�u ICH RRENT LOCAL AGENCY FACILITY IIDe# APPROVED BY NAME PHONE#WITH AREA CODE fv RMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ECKK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY:/ FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY