COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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STATE OF CALIFO WATER RESOURCES CON( ) ARD :,•�. FORM V: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING,INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT E�5 CHANGE OF INFORMATION ❑7 PERMANENTLY L AN 1 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6TEMPO TAN _ef [:]8 TANK REMO Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: $p i6li C mpany Fac i i t S i 1 F R 194 M TANK-YES X � 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ` ul CO A OWNERS TANK IDM B. MANUFACTURED BY: C� C.YEAR INSTALLED 1986 D. TANK CAPACITY IN GALLONS: 10,OOO 11. 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 UN ADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL X❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE Cl 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# CA.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.a D A.TYPE OF ®1 DOUBLE WAUFD ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLEWALLEI ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEUIRON ❑2 STAINLESS OR Fx�3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOLOOMPA11BLEFRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER G.INTERIOR [--I1 RUBBER LINED F-12 ALKYD LINING F13 EPDXY UNING F-14 PHENOLIC UNING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? [:]YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TM OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTKNI ®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 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 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER c A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A ®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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS OP S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 5 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 OFGALLONS 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? [::]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANaNAM (PRINTED b=SI DATE Hollis May 31 1989 LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY M FACILITY IDM TANK ID M 01 CURRENT LOCAL AGENCY�FpAC�j�ITY 1 f APPROVED BY NAME PHONE f WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 'f CHECK f PERMIT AMOUNT SURCHARGE AMT. FEE CODE A ECEIPT If BY: FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIEU BY A FACILITY/SITE APPLICATION, FORM `A',It 0-1 RRENT FORM'A' HAS BEEN FILED ) ms's DATA PROCESSING COPY