COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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STATE OF CALIFORPI& WATER RESOURCES CON OARD FORM 'B': UND GROUND STORAGE TANK PRQGRI TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE r�JTANK REMOVED d a] II FACILITY/SITE NAME WHERE TANK IS INSTALLED: j S -TaGFARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: V C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 0 0 -V� :�J 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 ❑ 2 PETR EUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT OIL ❑ 1 PRO CT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL [�F E(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# j S^ xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINERKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F--] 1 STEEL/IRON ❑2 STAINLESS STEEL F-]3 FIBERGLASS F-14 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED 1:12 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 5 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT F-]b�95VUNKNOWL..I AP El FIBERGAREINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE N ❑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 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9 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 C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ACU�5 UNKNOWN A U 99 OTHER V. EAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �O�P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P S 7 PRESSURE TESTINGP S 9 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(AAO/YR) ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH L///'-' 2./ 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK IS�D``# EH U Lo V CURRENT LOCAL AGE/ [ CILIT�� _ ^ APPROVED BY NAME � PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL ATE PER IT EXPIRATIO DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANW A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY