COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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.,,,.,.._. .,;... ,,r-. .-c =.. r. --r. ,., .,-... -r; n_c •-.�<.q•y...err^.-,*I°^l�'-,+;^*..:.�ge�sucy'ric7:'ss�r'=".'�''«'1-�ws'.,r.?�isy��'ss�t+��•�w+�!.�.'v,v.^Ra.-�•�?r?.aR�n STATE OF CALIFORN# WATER RESOURCES CONT BOARD /yam. rhF FORM `B': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK '" 'N K COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. F "�'P j�'J MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMA SED TA ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMQ,IL6D I FACILITY/SITE NAME WHERE TANK IS INSTALLED: f '(! FARM TANK - YES ❑ NO Z 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY 441161 A. OWNERS TANK ID # B. MANUFACTURED BY: boa" (ALAkdilmk to I C. YEAR INSTALLED i D. TANK CAPACITY IN GALLONS: �a _ Kz ry prli 11. TANK CONTENTS IF (A.1). IS MARKED, COMPLETE ITEM C. IF (A.il. IS NOT MARKED. COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCTOIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS 0 80 EMPTY ❑ 95 UNKNOWNASTE ❑ 99 OTHER ❑ 7 METHANOL 5; 9' HfHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF, HAZARDOUS SUBSTANCE STORED & C.A.S. # u � i e ®( C.A.S. #: `t5 x111. TANK CONSTIW CTION 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 B. CONSTRUCTION ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 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 C. INTERIOR F-11 RUBBER LINED ❑ 2 SW LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ NO ❑ 99 OTHER 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 IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A JFY3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER PERMIT AMOUNT A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A04 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 U 95 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 WELL1_�f S 4 ELECTRONIC MONITOR P S 5 GROUND WATER 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 u/ 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # Eolal qlolql SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:]NO /hq- GALLONS PHONE # WITH AREA CODE 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) I DATE LOCAL AGENCY USE ONLY COUNTY # � JURISDICTION # 11 1 11 AGENCY # 1 1 1 1 FACILITY ID # Eolal qlolql TANK ID # LololoIGI CURRENT LOCAL AGENCY FACILITY D # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE AERMIt EXPIRA ON DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIMBY A FACILITY/SITE APPLICATION, FORM `A', UNLESS ATURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY m