COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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...� i r I �r_� f 4 . 4;'el e: '.%x Whi`'f�[i 'I. P" 'si. v. M��.. . 'i.s.:. .. .. �a.��X fs4 'o'J Pr'•.' c'k 1 P'-il�i'M[` / "� �Rl%. _ _�r,,�..�. _ STATE OF CALIFOR WATER RESOURCES CONT OARD FORM `B': UNDE GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION -., -- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. M 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 ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: c2go C: FARM TANK - YES ❑ NO _ I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # Utje, B. MANUFACTURED BY: ()ic C. YEAR INSTALLED lq j D. TANK CAPACITY IN GALLONS: h9c II. TANK CONTENTS IF (A.1I. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED_ COMPLETE ITEM D_ A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. ❑ 1 DOUBLE WALLED C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-]3 CHEMICAL PRODUCT IL F-11 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN � ASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF 7j3 tp HAZARDOUS SUBSTANCE STORED & C.A.S. # - [ c x111. 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,MGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION ��EEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP U 1 STEEL/IRON ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 4 FIBERGLASS PIPE ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 4>11'UNED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTIONff>140'NE ❑ 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 9 OTHER B. CONSTRUCTION A ial 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 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. PS 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 P& 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 FAC)ILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO CUR ENT LOCAL AGENCY FACILITY ID # V, ae GALLONS I A P 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 # I I I I AGENCY # E[ FAC)ILITY ID # TANK ID # o ' JA CUR ENT LOCAL AGENCY FACILITY ID # V, ae A P ED BY N7ym& PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT kXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIE'u BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AMRRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY