COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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rr...,.-...:y;: r- : •rs*- +r• -,.;7[r '= T"c:.,,e °t'3R�1?' ,!%'r'S7!°7�;' '4'3"�'A'" '_:.... -rw STATE OF CALIFORN WATER RESOURCES CONTR PBOARD h FORM `B': UND GROUND STORAGE TANK PR GRAM TANK TANK PERMIT APPLICATION INFORMATION F COMPLETE A SEPARATE FORM WITH THE FOLLOWING I FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [13-5*"r-HANGE 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: ! (�� 7Zid FARM TANK - YES ❑ NO M1111111% LPr.0%onlr I 1 V FV COMPLETE ALL ITEMS- IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID # ✓ B. MANUFACTURED BY: C. YEAR INSTALLED iclov D. 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. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL N1 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. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX/1, B, C, & D I A. TYPE OF UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION F-11 STEEL/IRON ❑ 2 STAINLESS STEEL E]3 FIBERGLASS �.fr7EE L CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-15 CONCRETE E]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALW LINING ❑ 3 EPDXY LINING ❑ n -''_N( UC LINING LINING ❑ 5 GLASS LINING UNUNED A 8 100% METHANOL COMPATIBLE FRP r ,iKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO u 99 OT R D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT L I ' "i''WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE r JNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U_ 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A Q3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER � /,S/- A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM .. y, CONCRETE A U 7 STEEL CLAD W/FRP A 8 100% METHANOL COMPATIBLE FRP PERMIT AMOUNT A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER BY: V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. vrj_6 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS (7X 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P &91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U) (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS 1 ! lo -L -(k] 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 # AGENCY # FACILITY ID # TANNK ID # EN 1:1© 1 ! lo -L -(k] Lo I d I (ol --5t CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE # WITH AREA CODE .� PU r is � /,S/- PERMIT NUMBER PERMIT APPeROV/ALD P RMIT EXPIR ION DATE 'V CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEDW A FACILITY/SITE APPLICATION, FORM 'A', UNLESS ALL!1RENT FORM'A' HAS BEEN FILED v DATA PROCESSING COPY