COMPLIANCE INFO_1987-2000 - Laserfiche WebLink

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STATE 1 ATE. ,RESOURCES CONTROARD FORM '13': UNDEAROUND STORAGETANK PRONAM �o TANK PERMIT APPLICATION INFORMATION TANK CO)OPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY 1 NEIPERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM DNTERIM PERMIT F--j 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAMEWHERE TANK IS INSTALLED: FARM TANK-YES 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED 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. A�MOETMOJF VEHICLE FUEL � 2 PETROLEUM B. C. 1 UNLEADED E]2 LEADED 3 DIESEL CAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS Q 5 HAZARDOUS 80 EMPTY 0 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,13,C,a D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN SYSTEMff�l1NGLE WALLED ❑4 SECONDARY CONTAINMENT ®99 OTHER i STEEL/IRON ®2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYL CHLORIDE ®7 ALUMINUM Q 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL i ®95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING F-]4 PHENOLIC LINING LINING ❑5 GLASS LINING LINED ❑95 UNKNOWN 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 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAVqN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A t SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.'CONSTRUCTION A 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 1'STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A 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 SY TE CIRCLE P FOR PRIMARY,OR FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK S INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 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 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 [PERMIT Y# JURISDICTION# AGENCY# FACILITY ID# TANK ID# LI-1 Aa I b r I CAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT LSURCHARGE AMT. FEE CODE ECEIPT# BY: FORM B(6-29-s8)'THIS FORM MUST BE ACCOMPANIffFY A FACILITY CATION, FOR 'A',UNLESS A RENT FORMA' HAS BEEN FILED PROCESSINGDATA Y