COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

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FORM 'B': UNDGROUND STORAGE TANK PRl"'RAt>�I A�� TAN ERIVIIT APPLICATION iNFOR ION N � COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I 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 ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Exxon RAS # FARM TANK-YES❑ NO ❑R 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY I c A. OWNERS TANK ION 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. tG A. © 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ®1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ®1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS 80 EMPTY ❑95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM_O.BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.3 D A.TYPE OF ❑ i DOUBLE WALLED ❑3 SINGLE WALLED WITH U TERIOR LINER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALLED ❑4 SECONDARY CONTAINWENT ❑99 OTHER m I STEEUIRBM ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP 9 BR04ZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C.INTERIOR I RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOUCUNING 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 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 (q)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION AU�1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A (1 1 STEELttROW-' 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 W7FRP A U 8 10D%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 OPS 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 SUBSTANCE REMAI NG IN GALLONS INERT MATERIAL? [:]YES [:]NO THIS FORM HAS BEE O kWgER PENALTY OF PER#Y.4 TplfHE BEST OF MY KNOWLEDGE.14 TRUE AND CORRECT. APPLICANTS M C TED,3 E) DATE �.l (] ANALYST xl+qy LOCAL AGENCY USE ONLY 'Ccu::.1 a JURISDICTION! AGENCY N FACILITY ID i - TANK ID 11 I IT] 1 1 Flvl-A774 121- CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK K PERMIT AMOUNT SURCHARGE AMT FEE CODE RECEIPT• BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BMA FACILITY/SITE APPLICATION, FORM 'A',UjVA C&NT FORMA' HAS BEEN FILED 06 DATA PROCESSING COPY