COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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,�'"`w a>„?r.'y n":H w,. i.,'.-;r,'84""E.r+"'q..gT...i;`•;-"'•"c?rj"°"'rtr`+"7,T"„di��C'va'`a+y°°F':�nc..z-a,rsrye�R`wa3i !' _ '...;.J3 STATE OF CALIFORIN"J"'D WATER RESOURCES CONTIOARD FORM IB': UNDERGROUND STORAGE TANK PROGRAM TALK TANK PERMIT APPL—IC-ATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. SEI'c `t�f �a MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 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:�Q6 0,2� 1�%LT SSC A/FARM TANK - YES ❑ NO PF VG�7V RIr- 1 1VI\ GVMYLCIC ALL I ICMJ - Ir urww VwP1 — SV SYCGIrT A. OWNERS TANK ID # 41d B. MANUFACTURED BY: xi�gx's C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: D000 II. TANK CONTENTS IF (A.1), IS MARKED. COMPLETE ITEM C. IF (A.1). IS NOT MARKED. COMPLETE ITEM D. 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. #: 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 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL EP -T -FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U 2 STAINLESS STEEL F-11 RUBBER LINED F-12 ALKYD LINING F-]3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING F-]5 GLASS LINING E�t6 UNLINED A ❑ 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 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 PPRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U3 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 JL 7 STEEL CLAD W/FRRPQ� A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN <U)99 OTHER F►06969 1125 VIMWI�Y 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 PINVENTORY RECONCILIATION P S 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 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 FACILITY ID # Lo Lo f/ Iq b�- SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO I GALLONS PHONE # WITH AREA CODE 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 # J AGENCY # El I I FACILITY ID # Lo Lo f/ Iq b�- TANK ID # IE�l CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME (/ PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXPIRATION DATE CHECK # --rPERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: mmmomma FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEMY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A=RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 11