COMPLIANCE INFO_1986-1993 - Laserfiche WebLink

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,.4-77- ^ ., "' j..,,F•... `,.... STATE OF CALIFORN WATER RESOURCES CONT OARD FORM 'B': UNDL GROUND STORAGE TANK PR -RAM TANK TANK PERMIT APPLICATION INFORMATION j COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION;FOR EACH TANK. QFG MARK ONLY FL 'ANEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY C6QSEUIANK { ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED o a �+�-y� i FACILITY/SITE NAME WHERE TANK IS INSTALLED: , FARM TANK-YES❑ NO j 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 A. OWNERS TANK ID# Q B. MANUFACTURED BY: C.YEAR INSTALLED L I 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. 0 1 MOTOR VEHICLE FUEL 2 PETROLEUMB. C. ❑ 1 UNLEADED [:] 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OILPr RODUCT ❑4 GASAHOL F-] 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY E] 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.#: 1 x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL F-]3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE F-] 7 ALUMINUM F-18 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ ❑ ❑ ❑ PROTECTION 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 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 I C. MATERIAL A U 5 ALUMINUM A 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. 1 P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORIN&WELLS P 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 LASI USED(MO/YR) 2.,ESTIMATED UANTITY OF 3.WAS TANK, LED WITH If j SUBS R AINING IN INET A AAL? ❑YES ❑ NO GALLONS THIS FORM HA BEEN COMPLETED UNDER PENALTY D ERJURY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY PPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# TANK IDl# 610 6ENCY FACILITY ID# APP ED BY N E PHONE#WITH AREA CODE IT AP O AL DAT PERMIT EXPIRATION DATE IVPERMIT AMOUNT SURCHA GEA FEE CODE RECEIPT# BY: V FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM IN UNLESS A CI- ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY