COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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:�.., ,y. K'j;"t:i •fir.:} .. >.:,:�+�. .� . 3 �'w ��.s cR,.^e y ,�,'v,.,erc..tc $ "�+'r .::'�a?' -3 '3"°,i, r'�f•=.T'g'f �c 'df6"Y"'f'4,�..::;dti t�"_ r,.it '"ph;'§t4 ��;`''T� STATE OF CALIFORN WATER RESOURCES CONT OARD FORM `B': UND RGROUND STORAGE TANK PR GRAM a TANK PERMIT APPLICATION INFORMATION --- T-Q11tK - — -- ' — — 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 TAN ONE ITEM F-]2 INTERIM PERMIT [:]4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE [_]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:og c^ FARM TANK - YES ❑ NOof TANK DE5CHIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: ' E C. YEAR INSTALLED qlils� I D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM O_ A.1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 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. #: All. 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 3 GRAVITY ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS F-]4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP UP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A F-]1 RUBBER LINED E]2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING UNLINED Ej 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 T 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 IV2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A UP 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER RECEIPT # 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 CLA-DEW/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A 99 OTHER r/f?a I lalS_ --r.,; V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY. OR S FOR SECONDARY. A PRIMARY LEAK DETECTION SYSTEM MUST RE CIRCLED_ P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS 0 S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # 1()j()j1jqj_5__-[5] SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO CURRENT LOCAL AGENCY FACILITY ID # GALLONS I 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[ I I FACILITY ID # 1()j()j1jqj_5__-[5] TANK ID # -FnIc�l,,51 CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME j PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA E PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIMY A FACILITY/SITE APPLICATION, FUHM 'A', UNLESS AMRRENT FORM `N HAS BEEN FILED DATA PROCESSING COPY 1