COMPLIANCE INFO_1992-2001 - Laserfiche WebLink

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STATE OF CALIFORN11a WATER RESOURCES CONTRARD FOAM `B': UNDO GROUND STORAGE TANK PRO AM _ wo 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 rr'lt� NK ONE ITEM F—]2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: (, aLll C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F--] 2 PETROLEUM B. C•1 UNLEADED 0 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS El 5 HAZARDOUS Ej 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. # IVIA C.A.S. # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 BLE WALLED F—]3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN A U 99 OTHER 2-1-STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/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 2 STAINLESS STEEL ❑ 1 RUBBER LINED ❑ 2 AL D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED U ❑ 95 UNKNOWN ,I ,d A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO99OTHER�y ��"►� D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VItyYL 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 AU SU ST REMAINING IN PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION CURRENT LOCAL AGENCY FAC ID # U 1 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 0 95 UNKNOWN A U 99 OTHER ,-,W LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK op P) S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 59 6 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. ESTIMAT D QUANTITY OF 3. WAS TAN FILLED WITH FACILITY ID # SU ST REMAINING IN INER M E IAL? ❑ YES ❑ NO GALLONS Lp0--�—] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY. AND TO THE BEST OF MY KNOWLEDfGE. IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # Lp0--�—] D I ® u' CURRENT LOCAL AGENCY FAC ID # APPROVED BY NA �z PHONE # WITH AREA CODE ,4 /4 PE MIT NUMBER PERMIT APP OVAL D TE PERMIT EXP RA ON DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: ommmmomm FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIEUTY A FACILITY/SITE APPLICATION, FUHM 'A', UNLESS ALLTRRRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY