COMPLIANCE INFO_1986-1994 - Laserfiche WebLink

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�"...v�r..sY�+sa9er.`d'6•, K'�'-"'.�E`Rr.,c<ii`�la";s`, , . •: ,.. , - - ... ... �.. _„., �: . , , , _.. ..... .'+tom �.:...,v..r+.ra.. •,.:.,.".•.,rcacv.vary,i�"'.z'�'�"".'•`€'"S.'�.T'�?F`�S�F�'�-^' *� STATE OF CALIFOR WATER RESOURCES CONI&L BOARD yF; rF FORM V: UN RGROUND STORAGE TANK PFTOGRAM .s TANK TANK PERMIT APPLICATION INFORMATION 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 (� FACILITY/SITE NAME WHERE TANK IS INSTALLED: A-Q� FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: GC/ C. YEAR INSTALLED [3 D. TANK CAPACITY IN GALLONS: /0,000 11. TANK CONTENTS IF (A.1). IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F 2 PETROLEUM B. C. [:] 1 UNLEADED E012 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 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 ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 9M 2 SINGLE WALLED pm ❑ 4 SECONDARY CONTAINMENT If 99 OTHER A F-11 STEEL/IRON ❑ 2 STAINLESSSTEEL 3 FIBERGLASS F-]4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP A [:]9 BRONZE ❑ 10 GALVANIZED STEEL U� 9 UNKNOWN ❑ 99 OTHER U 5 ALUMINUM A U F-11 RUBBER LINED [W:]'2 KYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR LINING F-15 GLASS LINING LINED UNKNOWN ❑ 95 UNKNOWN U 99 OTHER ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION LLjy' 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 U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U, 95 UNKNOWN A U 99 OTHER PERMIT NUMBER A U i 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 SURCHARG AMT. A U 9 GALVANIZED STEEL A 095 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 1 VISUAL CHECK 10 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P &6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P (299 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 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 # —7 . WAS TANK FILLED WITH FACILITY I`D # SUBSTANCE REMAINING IN NERT MATERIAL? YES NO GALLONS 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 I`D # TANK ID # O CURRENT LOC L AGENCY FACILITY ID # yr APPROV D BY IN E , PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL IWTd PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARG AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIE V'A FACILITY/SITE APPLICATION, FORM `A% UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY