COMPLIANCE INFO_1989-2001 - Laserfiche WebLink

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r'; ...'%-;•� 13. ,.>;_ ., ,,�•-„! 5 3:,,,t,,•ri--*J� •' "P',Sres.,^gE^s,`", �`^'Wrkl ',,., t . STATE OF CALIFORI WATER RESOURCES CONT yE^ OF F FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION _.,� ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 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: Q , � JIj FARM TANK - YES ❑ NO y. I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY 0 A. OWNERS TANK ID # LAJ B. MANUFACTURED BY: C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: "500CD II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED. COMPLETE ITEM D. \'1 A �MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. NLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ODUCT ❑ 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 y�YSIRGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION Kl E /IRON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E] 95 UNKNOWN 99 OTHER ❑ 1 RUBBER LINED El2 ALKYD LINING F—]3 EPDXY LINING F—]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING EPA-4%NED C. MATERIAL ❑ 95 UNKNOWN 5 ALUMINUM ❑ 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 ED-9,�NBfiE ❑ 95 UNKNOWN ❑ 99 OTHER rlrli'§%X II117WIM M 1 IVIN t.:IHI:Lt A II- ACUVt UHUUNU, U IF UNULHUHUUNU, RUTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A&.A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER PERMIT AMOUNT I Al SURCHARGE AMT. FEE CODE RECEIPT # BY: Li 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. 1 VISUAL CHECK & S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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 FACILITY ID # I d ci I / I q I -5qD]'- SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑ NO 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. APPLICANTS NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY # = JURISDICTION # I I I I AGENCY # EI I I FACILITY ID # I d ci I / I q I -5qD]'- TANK ID # V-0 I (i [-,�,> I ICOUNTY CUgRENT LOCAEN - FA ILITY ID # APPR VED BY NAME K A li q zu— PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA E PER IT XPI ATION DATE CHECK # PERMIT AMOUNT I Al SURCHARGE AMT. FEE CODE RECEIPT # BY: Li FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIMYA FACILITY/SITE APPLICATION, FORM 'A', UNLESS A"tTRRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY