COMPLIANCE INFO_1986-1990 - Laserfiche WebLink

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wa. -0806 STATE WATER RESOURCES CONTROARD FORM ' MSGROUND STORAGE TANK PROGRAMo TAN Av �AANK PERMIT APPLICATION INFORMATION [A111� Mar»OIG�ALM SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK�7N�tY� � / p fALIn ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM PERV s'E£p}w ❑4 AMENDED PERMIT �6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ffig FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4�e ARM TANK-YES❑ NO �© I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN O SPECIFY A. OWNERS TANK ID# ! o B. MANUFACTURED BY: O s C. YEAR INSTALLED 8 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. ^+R A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL V❑ CHEMICAL PRODUCT ❑ 4 OIL E];,PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 55 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN Vr2 WASTE ❑ 7 METHANOL V9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ,•/ HAZARDOUS SUBSTANCE STORED&C.A.S.# k1l,B 7�r_ 611 C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-] 1 STEEL/IRON ❑ 2 STAINLESS STEEL V3 FIBERGLASS F-14 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-] 1 RUBBER LINED ❑ 2 ALKYD LINING ❑3 EPDXY LINING F-]4 PHENOLIC LINING �—�/ LINING [L/I 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYEfHLENE 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 A U 2 PRESSURE A(g3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A19 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 0 4 FIBERGLASS PIPE A U 91 NONE 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®1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS ®S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLIC�NAME8 SIGNA URE) I DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# r3_71 lololll ,71y- l �d 6 -1 CURRENTLSA AGENCY FACILITY IDr APPROVED BY AME^� PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE ERMIIIT'EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY