COMPLIANCE INFO_1985-1995 - Laserfiche WebLink

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;�sw^rT,m.+ .m•.s '��•�n�+�'le+.^-- w..'4^'^�.'�,.'�'^,r.r ...,.F. _�.�..,..�d • -rs+�.F*�x�-,�.'-^.^ .........,.r*'='.r.' p.,r,x,^...:,..-* c-,-m:-+-,-� �-�^.',;^.r r.. STATE OF CALIFORNAk WATER RESOURCES CON BOARD yE�o T NP, a FORM V: UNYGROUND STORAGE TANK PROGRAM TANK 'TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. „o k ilr� MARK ONLY F 1: NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Q� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY « t? A. OWNERS TANK ID # --- B. MANUFACTURED BY: I'd C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CQNTENTS 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.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 D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM INGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 4 FIBERGLASS PIPE F-11 RUBBER LINED F-]2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING E3 -,r GRED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAPAR 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 %,� SUCTION A PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER SURCHARGE AMT. A U STEEL/IRON 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 SS1� VISUAL CHECK w 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I P/iS �6 PRECISION TESTING PP S 7 PRESSURETESTING 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 FACILITY ID # I I I / I / I z SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO (� GALLONS I 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 LCL—*ftENCY LISF ONLY COUNTY # LEI JURISDICTION # I I I I AGENCY # [I I I FACILITY ID # I I I / I / I z TANK ID # Eolcjlv CURRENT LOCAL AGENCY FA' CILITY ID # 1 (� APPROVED B ME /6/�� P E # 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 BY ATACILITY/SITE APPLICATION, FUHM 'A', UNLESS A'CORREIrf FORM `A+ HAS BEEN FILED DATA PROCESSING COPY