COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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� ,..,9.R��,-4.....�-zor-�rc-•r'�'is'�psi'>I`lq�"7,7�F°2FF'�F'c�rF'a7i�k�TM'TR`�d�'�?s�pf'�+f1F" -�'F"" STATE OF CALIFORIM WATER RESOURCES CONT BOARD FORM V: UN RGROUND STORAGE TANK PR6GRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING !qPORMATION FOR EACH TANK. N4 MR MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 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: FARM TANK - YES ❑ NO � FkNl% Ur_*%o lr I I V IY COMPLETE ALL ITEMS -IF UNKNOWN —SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK LF C14 - - - -- 1r \A. I), 1.7 MAnneu, L VMPLE 1 E I I EM GL. Ir JAA), I, NU 1 MAHREU, GUMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL F—]3 CHEMICAL PRODUCT F-14 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS [::] 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE E] 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. #kj/t+—C.A.S. #: x111. TANK CONSTRRYCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS EL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE F-16 POLYVINYLCHLORIDE F-17 ALUMINUM 8 100% METHANOL COMPATIBLE FRP RECEIPT # ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-11 RUBBER LINED D LINING U12NOLINED F-13 EPDXY LINING ❑ 4 P"- -' '^ LINING r LINING F-15 GLASS LINING A U 6 CONCRETE .4N U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ NO E:] 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ ? ' '- "'RAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE r 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 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER RECEIPT # A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) AID 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 Ar >5 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 P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS (P 4 S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P al NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USM /) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN AGENCY # FACILITY ID # EI I I lo lo I I lql a 3. WAS TANK FILLED WITH INERT MATERIAL? ❑ YES [:]NO APPROVED BY N ME 8 is' PHONE #WITH AREA CODE GALLONS PERMIT APPROVAL D ,lV / 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 # ❑j JURISDICTION # I I I I AGENCY # FACILITY ID # EI I I lo lo I I lql a TANK ID # Eolc) CURRENT LOCAL AGENCY FACILITYYD # Poo � APPROVED BY N ME 8 is' PHONE #WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL D ,lV / ERMI EXPIRATI DATE CHECK # PERMIT AMOUNT , SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEUTY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A �'ii, RRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY r