COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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STATE OF CALIFORN WATER RESOURCES CONTR*ARD y<•;�: rHf FORM `B': UNDE GROUND STORAGE TANK PROGRAM 4o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Fa '" MARK ONLY tg I-NEWf@Wff-- ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATIONV8TANK ANENTLY CLOSED TANK ONE ITEM El INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Lrj_=Vnn FARM TANK-YES❑ NO Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# Am1L -w cp B. MANUFACTURED BY: C. YEAR INSTALLED 1990 D. TANK CAPACITY IN GALLONS: Q = Wb II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Cid A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT CK4 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.# 3 O 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 ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL LCA"FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE MATERIAL ❑6 POLYVINYL CHLORIDE F-] 7 ALUMINUM ❑8 1 W%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-]3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN 5<IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP 5K4 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 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 0 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 Q)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 I 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 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT5 LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH °'7 V � LOINSSUBSTANCE REMAINING IN INERT MATERIAL? F-]YESNO G/ THIS fAdREEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE EST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE c E r gs ),�TT �•2��90 LOCAL AGENCY USE ONLY E JURISDICTION# AGENCY# FACILITY ID# TANK ID# 13711 l101 AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE LD3 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE al PERMIT AMOUNT SURCHARGE AMT. FEE CODE R IPT# BY: L2 FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE6 FACILITY/SITE APPLICATION, FORM`A',UNLESSA CMkNT FORM A' HAS BEEN FILED DATA PROCESSING COPY