COMPLIANCE INFO_1985-1995 DOUBLE CHECK

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ti Ni [ 3..-+. x a.. .v .., . � ._.� r. .',i i -s l,�!.. '_•rF,rc,.'4,Ap.. Te'e,� ';] s++tv� w,.«».vc;V'go: xaw *r,.,. x,�, ... ,..�.r •ac 4.pf+F`a,, .pz•�,y,ll.;.=. i T"�3'P STATE OF CALIFORNI WATER RESOURCES CONTRSOARD S�P.�. FORM'B'; UNDLfGROUND STORAGE TANK PROAM , TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ill O N P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT &1 -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:�2-1 FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: �r1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: TANK CONTENTS IF (A.1), IS MARKED. COMPLETE ITEM C. IF (A.1). IS NOT MARKED. COMPLETE ITEM D. A. 5�-r MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED Z�;IESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ®-1 PRODUCT E]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 l'2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 1 SINGLE WALLED A U 2 DOUBLE WALLED ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ® FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP C. MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER A U 8 100% METHANOL COMPATIBLE FRP ❑ 1 RUBBER LINED E]2 ALKYD LINING F-]3 EPDXY LINING F-]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING Q-15 UNLINED ❑ 95 UNKNOWN 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 CQ -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 AU02 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 5 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP BY: A U 9 GALVANIZED STEEL A� 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 t.:i S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND MONITORING WEL P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 9 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 FAC/IILITY ID # �/1 /�o SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:]NO 1 AGENCY FACILITY ID # EPERMITAIUMBER GALLONS APPROVED BY NAME 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 OrFNCY 11SF nNLY FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEDM A FACILITY/SITE APPLICATION, F V HM -A-, UNLESS A C .71RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY JURISDICTION # AGENCY # EEEI FAC/IILITY ID # �/1 /�o TANK ID ##1 Eg [�) I } I eA AGENCY FACILITY ID # EPERMITAIUMBER APPROVED BY NAME PHONE # WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPPERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEDM A FACILITY/SITE APPLICATION, F V HM -A-, UNLESS A C .71RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY