COMPLIANCE INFO_1986-1998 - Laserfiche WebLink

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�i`� I►`� I� C Ih CIp LIF IR wA�ER R souRc�s coNr� P o,�RD ®i�.�I. iWIM'. UND1 ■iOuN® VMr®YBaME raNOR tl R1A a ~ TANK = TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. c,m z M ARK ONLY ❑ NEW PERMIT F]3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO K10 NE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ®6 TEMPORARY TANK CLOSURE 8 TANK REMOVED a NAME WHERE TANK 18 INSTALLED: ,/ �' !G FARM TANK-YES[-] NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-So SPECIFY W Q A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED ( D. TANK CAPACITY IN GALLONS: UF( 00 If. TANK 2ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,pd^MPLETE ITEM D. A. 0 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ®, C 1 UNLEADED ®2 LEADED E]3 DIESEL ®3 CHEMICAL PRODUCT 0 4 OIL IPRODUCT ®4 GASAHOL Ej 5 JET FUEL ®6 AVIATION GAS ®5 HAZARDOUS ❑80 EMPTY ®95 UNKNOWN ❑2 WASTE ❑7 METHANOL F-1 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.M C.A.S.N: ILL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,&D A.TYPE OF ❑1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER Q 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK ❑ i STEBARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS E:]4 STEEL CLA)W/RBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE E 6 POLYVINYL CHLORIDE f__j 7 ALUMINUM F_�8 100%METHANOL COMPATIBLE FRP 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN ❑99 OTHER C.INTERIOR Q I RUBBER LINED ❑2 ALKYO LINING ❑3 EPDXY LINING F-1 4 PHENOLIC LINING LINING ❑5 GLASS LINING ®61NLINED M 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH I W%METHANOL? El YES ❑NO ®99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP E]2 TAR OR ASPHALT F-1 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 i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE 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 I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATVN ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATELAST USED(MO/YR) 2.ESTIMATED QUANTITY Of SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH GALLONS INERT MATERIAL? F-1 YES F-1 NO THIS FORM.HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APR4ICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGE ...? Y USE ONLY COUNTY 8 i JURISDICTION 0 AGENCY M FACILITY IDP TANKJCODE l ® s--RENT LOCA L AGENCY EaMITYAPPROVED BY NAME PHONE N WITH PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK Y PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT k BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANIED ACRJTYlSrM APPLICATION, FORM `A',UNLESS A C NT FORMA' HAS BEEN FLIED DATA PROCESSING COPY