COMPLIANCE INFO_1986-1994 - Laserfiche WebLink

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STATE OF CALIFOR10 WATER RESOURCES CONIM BOARD FORM 'B': UN RGROUND STORAGE TANK PRUGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ori NEW PERMIT ❑ 3 RENEWAL PERMIT F-]5 CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED TANK ONE ITEM TeINTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED:DL iSaa �c�l@ v, FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # w/k-, B. MANUFACTURED BY: C. YEAR INSTALLED 14 D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.1). IS MARKED. COMPLETE ITEM C. IF (A.1). IS NOT MARKED. COMPLETE ITEM D. p A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑OIL 1:11 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ©,�ASTE ❑ 7 METHANOL 9 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # w(,° ste of'/ C.A.S. #: o x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C,& D A. TYPE OF ❑ 1 DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM j 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLADW/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 F-11 RUBBER LINED F-12 ALKYD LINING ❑ 3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED U CONCRETE 5 UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT F-] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE �5 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 (D95 UNKNOWN A U 99 OTHER 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 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP BY: A U 9 GALVANIZED STEEL At )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 1 VISUAL CHECK 0 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 196 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 QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # 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 LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # 10101 / I � oa114 CURRENT LOCAL 6QENCY FACILITY ID # APPRO ED Y ME PHONE # WITH AREA CODE r '^ PERMIT NUMBER PEERRMIIT APPROVAL D E PERMIT EXPIRATION DATE lJ / , 0� CHECK # PERMIT AMOUNT ....11SURCHAFObE AkfT. FEE CODE ECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEWY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AIIIIIIIRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY