COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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^+7�'r .2 ;v,^v�.clio"a:`%i 1;` ,'qtr.-'.._i„„,:'."',!'.�_?#�.':;-'4„1.T,", ..'lllPx•7�-""'.t?v"`•'"' tr' STATE OF CALIFORN WATER RESOURCES CONT BOARD FORM `B': UN I GROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT liKCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSUREANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6:/, FARM TANK - YES ❑ NO -� I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY 3 t IV, A. OWNERS TANK ID # 0' B. MANUFACTURED BY: U C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: TANK C0IFITENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED- CAMPLETE ITEM D_ A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 1 PBLE WALLED C. 1 UNLEADED ❑ 2 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. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF ❑ 1 PBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM SI WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL F-]3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE F-]7 ALUMINUM 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER C. MATERIAL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING [:]KPHE NING C. INTERIORLINING 5 GLASS LINING UNLINED A U 9 GALVANIZED STEEL A US UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 1 HANOL? YES ❑ NO FEE CODE RECEIPT # D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER NIHINU IIVrUHiMA I N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A&!Z A&! 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 3 LINED TRENCH U 5 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 C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A US UNKNOWN A U 99 OTHER FEE CODE RECEIPT # 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 S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST U D YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO I I I I GALLONS l'o 1V) / CV 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 # TANK ID # Ell I I I I E[ I I l'o 1V) / CV ZE 1:ola CURRENT LOCM.#GENCYF CILI ID # APPROVED BY NAM PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE ERMIf EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIEraY A FACILITY/SITE APPLICATION, FORM `A', UNLESS A MRENT FORMA' HAS BEEN FILED rar) DATA PROCESSING COPY