COMPLIANCE INFO_1986-1994 - Laserfiche WebLink

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STATE OF CALIFOR WATER RESOURCES CONBOARD FORM `B': UND RGROUND STORAGE TANK PR GRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 EW PERMIT F-]3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E]7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED V FACILITY/SITE NAME WHERE TANK IS INSTALLED: Sae.A ayok4,& Rol, FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # C-c'd< B. MANUFACTURED BY: u4< C. YEAR INSTALLED IFY3 1 D. TANK CAPACITY IN GALLONS: O DQ D II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. Zl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C• 1 UNLEADED 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-]4 OILPRODUCT SYSTEM ❑ 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. #: xlll. 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 ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 SINGLE WALLED A U 2 DOUBLE WALLED 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 8 100% METHANOL COMPATIBLE FRP ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH NOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED CHECK # Ej25 UNKNOWN SURCHAR AM ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? El YES E] NO E] 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT Lo 3 INYL 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 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 a 95 UNKNOWN A U 99 OTHER APPRO ED.VY ME A U 1 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 AI..J 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 1VISUAL CHECK OP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P a PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P1099 OTHER =P,&/ 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 # SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES E]NO NGALLONS fl E[ % 1 40 10 1 / I / 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 1 ACOL AnFNCV USE ANLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # ml I I I I E[ % 1 40 10 1 / I / I / %� [ 1 OT07P] CURRENT LOCAL AGENCY FACILITY ID # APPRO ED.VY ME PHONE # WITH AREA CODE e v r A � ZWZX� PERMIT NUMBER PERMITAPPROVALE PERMIT EXPIRATION DATE 4J / ` 9J CHECK # PERMIT AMOUNT SURCHAR AM FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEUV A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AWRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY 0