COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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STATE OF CALIFORNIO WATER RESOURCES CONTROARD FORM 'B': UNDERGROUND STORAGE TANK PROGRAMo TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATIONn PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO • I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# A 412 B. MANUFACTURED BY: XF-RAseo coftpoRgrlot-4 Q� C. YEAR INSTALLED 1410 D. TANK CAPACITY IN GALLONS: I o000 El II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. X1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 5�1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑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 OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-] 1 STEEL/IRON ❑2 STAINLESS STEEL �3 FIBERGLASS F-14 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑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-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? CgYES ❑ 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 6D 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A Q 1 SINGLE WALLED A U 2 DOUBLE WALLED A(9 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 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 O 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 ®®4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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. ESTIMA ED DAT LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH f� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES NO THk FORf4 HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE r-w&s-rm-;z_ ba*amem- 2b&go LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# E[ I LL 1119 1 cl 151 1 1 —OU-1 [PERMIT ENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE RDg1L. o NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATEK# PERMIT AMOUNT URCHARGE AMT. FEE CODE CEIPT# BY: f f FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING 0OPY