COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

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FOR?A `t3': UND GROUND STORAGE TANK PR RA[dt -TA"'NK TAN ERMIT APPLICATION INFORMWION 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 ❑8 TANK REMOVED /1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Exxon RAS # 7- 3` 6% FARM TANK-YES❑ NO Q 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I C A. OWNERS TANK ID# B. MANUFACTURED BY: h C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ~' If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CC A. 1 MOTOR VEHICLE FUEL Q 2 PETROLEUM B. C. 1 UNLEADED E]2 LEADED Ej 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS E]5 HAZARDOUS EMPTY ❑95 UNKNOWN ©2 WASTE ❑ 7 METHANOL ®99 OTHER(DESCRIBE IN ITEM,-D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# ti� C.A.S.#: xi Il. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.&D A.TYPE OF ❑I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER ©1 STEEL/(eN ❑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 BRONZE 10 GALVANIZED STEEL E]95 UNKNOWN E]99 OTHER C. INTERIOR 1 RUBBER UNED ❑2 ALKYD LINING 3 EPDXY LINING 4 PHENOL IC UNING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH I W%METHANOL? YES ❑NO ❑99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 VNfYL 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 U 2 PRESSURE A 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A l SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER AfUJ 1 STEELmR@N A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U S.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 3 1 VISUAL CHECK �S 2 INVENTORY REC.ONCIUATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P E 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 OUANTITY OF 1 3.WAS TANK EILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? n YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY N TH BEST OF MY KNOWLED .1'w TRUE AND CORRECT. APPLICANTS a( W E) 4 LZA IDATE U.G.T. ANALYST d � LOCAL AGENCY USE ONLY Coto:::-'€ii JURISDICTION• AGENCY* v FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILIT'IF-JIPIll APPROVED BY NAME PHONE R WITH AREA CODE ` PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 11 PERMIT AMOUNT SURCHARGE AML FEE CODE RECEIPT# BY: FORM B(3-7.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM IA',IWAI#ENT FORMA' HAS BEEN FILED 00 DATA PROCESSING COPY