COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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:.:,�°c•3��m-,,, �"r3'..:,'^,?�., ni�;,r, w-.-.-..r.-r-f: :ra,•-.^rs•..��.sg'p„`—."°=r4-�-ti,�-.�r�.'°°'••'��4'""-"'_�'�'sf"'�rnRi'i'.t'�q"�r"VSnr,��fl!"%1"' �,J(�'n'e+V��rs;rrr-,.�,�v�e;" ,}'—,��- ....,�i �s rr......-e�« +wcr STATE OF CALIFORINIM WATER RESOURCES CONT*OARD � FORM `B': UNDERGROUND STORAGE TANK PROGRAMTA e TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 55 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: �� _ FARM TANK - YES ❑ NO 4 I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # N ON B. MANUFACTURED BY: 0i_ C. YEAR INSTALLED 7^ D. TANK CAPACITY IN GALLONS: 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 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL1 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 ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM Ej�,PSMGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U NKSTEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP 3 LINED TRENCH A U ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER U ❑ 1 RUBBER LINED F-12 ALKYD LINING F-]3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING E4-9-mLINED 5 ALUMINUM A ❑ 95 UNKNOWN 6 CONCRETE ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER 1)..CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TSAR OR ASPHALT F-]3 VINYL WRAP El FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION �1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. F'IF'Imu IIYrunmpk 1 IVIV CIRCLE A IF ABa GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION W(Ujj INERT MATERIAL? D YES ❑ NO 1 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER jgEIPT* A 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. 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 1�) 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 FACILITY ID # f SUBSTANCE REMAINING IN INERT MATERIAL? D YES ❑ NO 1 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 # AGENCY # FACILITY ID # f TANK ID # CURRENT LOCAL AGENCY FACILITY ID # R APPR VED BY NAME L PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXF IRATI N DATE CHECK # PERMIT AMOUNT Allk SURCHARGE AMT. FEE CODE jgEIPT* BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIE-5 8YA FACILITY/SITE APPLICATION, FORM 'A', UNLESS )i=RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY