COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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STATE OFCALIFOR1411F WATER RESOURCES CONTRdMOARD UNDERGROUND STORAGE TANK PROGRAMxo TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o. 1 MARK ONLY ❑1,4EW PERMIT ®3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CMOK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED ro FACILITY/SITE NAME WHERE;TANK IS INSTALLED: , FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A.OWNERS TANK ID# B. MANUFACTURED BY C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: M. 11. TANK C2�TENTS IF(A.11),IS MARKED,COMPLETE ITEM CMF(A.1),IS NOT MARKED,,POMPLETE ITEM e A. 1 MOTOR VEHICLE FUEL ®2 PETROLEUM Bil/lPRODUCT C. 1 UNLEADED ®2 LEADED ❑:3 DIESEL 3 CHEMICAL PRODUCT F-14 OIL ®4 GASAHOL ❑5 JET FUEL E 6 AVIATION GAS 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,B,C,a D A.TYPE OF ® I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ®99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM �8 100%METHANOL COMPATIBLE FRP MATERIAL ❑.9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER ® 1 RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING 4 HENOUC LINING C.INTERIOR , LINING 5 GLASS LINING 6 UNLINED 95 UNKNOWN . 1S LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [::] NO 99 OTHER D.CORROSION ❑ I.POLYETHLENEWRAP ❑2'TARORASPHALTV95 WL' 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ®5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ®99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A V1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN -A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 95 UNKNOWN : A U 99 OTHER A U 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 U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9'GALVANIZED STEEL A U 5 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. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS vp 16 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF T3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I 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# CURRENT LOCAL AGENCY FACILITY 10# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNTSAiURCHARGE AMT. FEE CODE CEIPT# BY: FORM B(6.29-88) THIS FORM MUST BE ACCO ANI- BY A FACILITY/SITI; ' KATION, FOR `A' UNLESS; RENT FORMA' HAS BEEN FILED -,DATA MOSQ.MAly