COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

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FORfA `Q': UND ^GROUND STORAGE TANK PRQ" RARE " > �' TAN ERMIT APPLICATION INFOR ION NK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM.PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: Exxon RAS # 7- :!S. \O% FARM TANK-YES❑ NO Q 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO,SPECIFY i C A. OWNERS TANK IDH B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. 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 n 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL ®i PRODUCT ❑4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 2 WASTE 1:17 METHANOL E]99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.It C.A.S.a: xil1. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C.&D A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM ©2 SINGLEWALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER 1 STEEi" n 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 8.TANK ❑5 CONCRETE 6 POLYVINYL CHLORIDE n 7 ALUMINUM n 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL (-]95 UNKNOWN [-]99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UN114G LINING ❑5 GLASS LINING ®6 UNLINED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D.CORROSION ❑I POLYETHLENE WRAP 2 TAR OR ASPHALT n 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 1 SUCTION A ®2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A e)1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A Q)1 STEELOReW 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 I VISUAL CHECK �S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 5 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 OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, D Tq THf4EST OF MY KNOWLEDG§t IS RUE AND CORRECT. APPLICANT'S NAkj W ) DATE U.G.T. ANALYST d Lq LOCAL AGENCY USE ONLY cour::.9 i JURISDICTION Il AGENCY a FACILITY ID 11 TANK ID O CURRENT LOCAL AGEN Y FACILI 0• APPROVED BY NAME PHONE>f WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED PY A FACILITY/SITE APPLICATION, FORM `A',Ulf A*NT FORMA' HAS BEEN FILED 06 DATA PROCESSING COPY I/>J