COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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. €,: .e r . -.i ,. �" •:xC b : --3 r�¢x, avary� .K 'r-"�T6 "`4'' na' ." ��. .:-.z,.¢.-q�„r' r�°fx-aag..�++'°..f�;:'�'az"'t"�: s STATE OF CALIFORNIO WATER RESOURCES CONTROARD FORM'B': UNDERGROUND STORAGE TANK PROGRAMo TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. ;"- 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: `! UjN - 72CFARM TANK -YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY 20 A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED 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. A• 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 1 UNLEADED ? LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 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. #: N rr fX x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, I D A. TYPE OFDOUBLE 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 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP SURCHARGE AMT. ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ i RUBBER LINED 2D LNING 4-6'UN'LYINED' ❑ 3 EPDXY LINING ❑ 4 Pur•"� IC LINING LINING F-]5 GLASS LINING r„aNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOO ES E]NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ ? IAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE A _ 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED AU LINED TRENCH A U 95 UNKNOWN A U 99 OTHER SURCHARGE AMT. A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A 04 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 A X95 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 -p S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSa S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 091 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LASTU (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH T K I SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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 # I I I I FACILITY ID # AGENCY # LoLo El I I 14-1041 TANKID# loini-OT4-1 CURRENT LOCAL AGENCY FACILITY 10 # t APPROVED BY NA „� "616 PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPmiT PE MtT E PIbRATION ATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE..]jRECEIPT # BY: ` FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED'SY A FACILITY(SITE APPLICATION, FORM 'A', UNLESS AMRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY f -.,N