COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOR WATER RESOURCES CONTPWOARD gxE FORM V: UNI GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �4<IFO MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT EB/5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: +CJ FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I Gf A. OWNERS TANK ID# If B. MANUFACTURED BY: C. YEAR INSTALLED / D. TANK CAPACITY IN GALLONS: W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. A. F21 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. Ep"l UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Eel ❑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.# IV/!9" C.A.S.#: xlil. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 22 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER TEEL/IRON ❑2 STAINLESS STEEL F-13 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK1 S F-]MATERIAL 5 CONCRETE El6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 4KYD LINING F-]3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 26UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP �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 i SUCTION A a 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 95 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 CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 4095 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. ya P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS !r P S 6 PRECISION TESTING P S 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 OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN 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# [H] I I I I EI I I L2-Lo I / I Fq3 01 C I 6I —1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE �l /(P i PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE o © l 9 1.t ff9 I� 31 e CHECK# PERMIT AMOUNT SURCHARdEAMT.1 FEE CODE ECEIPT# BY: c FORM B(3-7-88) THIS FORM MUST BE ACCOMPA BY A FACILITY/SITE APPLICATION, FORM A,UNLES URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY