COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

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J k STATE OF CALIFORNI WATER RESOURCES CONTRO ARD FORM `B': UNDER ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION c` a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Wig= MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 4 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED !1 / FACILITY/SITE NAME WHERE TANK IS INSTALLED/(/F71 )(f 1:k4 FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # n B. MANUFACTURED BY: C. YEAR INSTALLED 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. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 60 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. #: r04 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 a2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER SINGLE WALLED A U 2 DOUBLE WALLED o"1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 8 100% METHANOL COMPATIBLE FRP ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-]3 EPDXY LINING F-14 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ©6 UNLINED FEE CODE ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP s 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 a 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A Wl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER © m �o I A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 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& 95 UNKNOWN A U 99 OTHER . SURCHARGE AMT. idlb V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P b 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. ESTIMATEDTE LAST USED (MO/YR) 2. ESTIMATE QUANTITY OF 3. WAS TAN FILLED WITH TANK ID # SUBST EMAINING IN INE T M RIAL? ❑ YES ❑ NO Lot GALLONS RRENT LOCAL AGENCY FAC ITY ID # THIS FOkM 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 # � I I I I EI I I Lot Tc-) 1I 1 RRENT LOCAL AGENCY FAC ITY ID # APPROVED BY NAM PHONE # WITH AREA CODE © m �o I L 7 u 16 RMIT NUMBER PERMIT APPRO AL ATE PERMIT PIRATION DATE , Acs cv u ECK # PERMIT AMOUNT . SURCHARGE AMT. idlb FEE CODE RECEIPT # BY:Li FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED -RA FACILITY/SITE APPLICATION, FORM `A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 7