COMPLIANCE INFO_1987-2000 - Laserfiche WebLink

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sw: F,�., 7,1 STATE OFCALIFORNI WATER RESOURCES CONTRO ARD" gt' °,`�f F O A TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I . MARK ONLY f2il NEWPERMIT ❑3 RENEWAL PERMIT F_�5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED TANK ONE ITEM n 21 TERIM PERMIT Ej 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Oo A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED K. D. TANK CAPACITY IN GALLONS: da 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEk .IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. l MOTOR VEHICLE FUEL r_�2 PETROLEUM B. C. F-] 1 UNLEADED ❑ 2 LEADED DIESEL 3 CHEMICAL PRODUCT F-] 4 OIL PRODUCT ®4 GASAHOL 5 JET FUEL ®6 AVIATION GAS 1 ® 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.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,6,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER EL/IRON ®2 STAINLESS STEEL ®3 FIBERGLASS �4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYL CHLORIDE ®7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ ib GALVANIZED STEEL` ❑95 UNKNOWN E]99 OTHER ❑i RUBBER LINED F-1 2 ALKYD LINING ®3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR LINING ❑ 5 GLASS LINING NLINED F 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES "❑ NO [_]19 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP E 2 TAR ORASPHALT O 3 VINYL WRAP 1 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ® 5 CATHODIC PROTECTION 1 NONE n WONKNOWN -]99 OTHER IV. PIPING INFOR A ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE , A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1'SINGLE WALLED A U 2 DOUBLE WALLED i A U 3 LINED TRENCH A'U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON' 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. S 1 VISUAL CHECK P' S 2 INVENTORY RECONCILIATION P $ 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS S 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 LACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO 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# TANK ID# = I I I i - L I ;T_6_� L J- I I_'A Li CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECif# PERMIT AMOUNT SURCHARGE AMT. FEE CODE CEIPT# BY: FORM a(6-29-66) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE ICATIO , FOR `A',UNLESS Ar RENT FORMA' HAS BEEN FILED S7 DATA PROCESSINGY