COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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,:.1;`�` �.x. '.�z�'FSvPv".;".'r f yr � �;;-: w .n..,u(+r- :,r. ,.Ya-,tris�.. ...::. ,,, z.: ..r.ri .•gym-:r �F �'"- ) .,R STATE OF CALIFOR WATER RESOURCES CON OARD y4�` TM1 f FORM `B': UND GROUNDSTORAGETANK PR RAM T TANK PERMIT APPLICATION INFORMATION 'm �� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 'S r FACILITY/SITE NAME WHERE TANK IS INSTALLED: .2," '75 f e6ty RX 77effy FARM TANK-YES❑ NO EAlf z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 b A. OWNERS TANK ID# B. MANUFACTURED BY: I C. YEAR INSTALLED ( D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CA? A. C , MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL - ❑ , PRO CT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN [Lj,,I?<ASTE ❑ 7 METHANOL ©�J OTHER(DESCRIBE IN ITEM D,BELOW) C D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �L I HAZARDOUS SUBSTANCE STORED&C.A.S.# �Li� 01 (, 6d46-#r� T+ x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF EIJI DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER i ❑ 1 STEEL/IRON ❑2 STAINLESS STEELEj;A'FBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE El6 POLYVINYLCHLORIDE F-]7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 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 ❑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 A iZ 2 PRESSURE A 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A&A 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) AC!!"°X A :!!"° 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 WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 1 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 3.WAS TANK FILLED WITH �J • ` GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO j THIS FORM HAS kEEN 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# EH o � I R e CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME i/ PHONE#WITH AREA CODE Mob L PERMIT NUMBER PERMIT APPROVAL TE P RMIT EXPIRATION DATE t [,J7)/ CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPAN A FACILITY/SITE APPLICATION, FORM`A',UNLESS RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY