COMPLIANCE INFO_1989-2008 - Laserfiche WebLink

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T- ,'Y% xk'"W ay �-'a%. :i.v 7 7 J-.1Y Na' R.Y"k' '3 F w b' .'*TAT OFC L.IFOF i WATtR RESOURCES,CONT BOARD yf^ TNF I AR FORM13: D GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION -r bMftE'YI=A iI?PARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH T'ANIS `< ^- MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' !O A\L, FARM TANK-YES❑ NO 1 TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 25.600 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. tX 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ®5 JET FUEL F-1 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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&v A.TYPE OF X-1 DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER F-�95 UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER 11 1 STEEL/IRON ®2 STAINLESS STEEL 3 FIBERGLASS ®4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE MATERIAL ❑fi POLYVINYL CHLORIDE ®7 ALUMINUM ®8 100%METHANOL COMPATIBLE FRP 9 BRONZE ❑ 10 GALVANIZED STEEL ®95 UNKNOWN ®99 OTHER ® C..INTERIOR 1 RUBBER LINED ®2 ALKYD LINING ❑3 EPDXY LINING ®4 PHENOLIC LINING LINING', ❑5 GLASS LINING F-1 6 UNLINED F-�95 UNKNOWN ®IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? -YES [:]NO ®99 OTHER LOTPR ROSION ❑ 1 POLYETHLENE WRAP F-12 TAR OR ASPHALT F-]3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC ECTION N [::]5 CATHODIC PROTECTION E:]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 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 ® 2 DOUBLE WALLED A U 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 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 FAUST BE CIRCLED. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS PDS 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 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 INERT MATERIAL? 0 YES ® NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P R URY AIV Tp THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE C.- LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I . I--_j EE 1 :7-1 A :5][21 Ill CURRENT LOCAL AGENCY FACT PTY ID# APPROVED BY NAME PHONE#WITH AREA CODE r PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT BU&PGE AMT. FEE CODE RECEI :_# BY: FORM B(6-29-88) THIS FORM MUST BE ACOOMPANIMSYA iWi ITY/SITE APPLICATION, FORM`A',UNLESS A' URRE FORM A' HAS BEEN FILED DATA PROCESSINGY :.