COMPLIANCE INFO_1992-2001 - Laserfiche WebLink

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NATE OF CALIFORN WATER RESOURCES CONTR OARD 0 UND19GROUND STORAGE TANK PROTRAM_ a TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �� ^ I. MARK ONLY1 NEW PERMIT F-� 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F-� 7 PERMANENTLY C K ONE ITEM 2 INTERIM PERMIT �,4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — 80 SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS:ZZ 1 II. TANK C214TENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. [Ell MOTOR VEHICLE FUEL ® 2 PETROLEUM 3 CHEMICAL PRODUCT ®4 OIL B. 1 PRODUCT C• � 1 UNLEADED ❑ 2 LEADED ff�3 DIESEL ❑ 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. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A, B, C, & D A. TYPE OF❑ 1 UBLE WALLED ® 3 SINGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE F-16 :, POLYVINYL CHLORIDE F-]7 ALUMINUM F-18100%METHANOLCOMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ® 99 OTHER 1 RUBBER LINED ❑ 2 A LINING ® 3 EPDXY LINING ® 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED ® 95 ?DOWN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES E] NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ® 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ®9t NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFOR ATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A, SYSTEM TYPE A U 1 SUCTION A U7 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U ` . SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 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 A U 91 NONE 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 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 8 1 VIS6L CHECK R S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P EZ6 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 THIS F RM 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 # El I Ii.1 [PERMIT ENT LOCAL AGENCY FACILITY ID # APPROVED BY NAM PHONE #WITH AREA CODE ZA NUMBER PERMIT APPR Da PE IT EXPIRATI DATE K # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT x BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANI A FACILifY/SITE CATION, FOR `A', UNLESS A' ENT FORMA' HAS BEEN FILED PROCESSINGDATA 1. ESTIMATED ATE LAST USED (MO/YR) 2. ESTIMAT D QUANTITY OF 3. WAS TANK FI LED WITH SU ST C REMAINING IN INERT AT I ? � YES � NO GALLONS