COMPLIANCE INFO_1987-2001 - Laserfiche WebLink

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... ..�.:. '""R"TFa. :"{}: F+i r_-,'.5.•.. r. t;--Y-77gn,TT'14 :�,1 �r, R.•, I}yr 'yF"`cq a1�...rq `, nq�v s*t'la'-^'s .z;, ,egY�rtrArrys�:rs� 7" STATE OF CALIFORN WATER RESOURCES CONT OARD FORM `BK ': UNDROUND STORAGE TAN PR F -' O TANK TANK PERMIT APPLICATION INFORMATION I COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " C'�llFO NaP MARK ONLY �1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I KI FACILITY/SITE NAME WHERE TANK IS INSTALLED: ��R I FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY A. OWNERS TANK ID # 2 B. MANUFACTURED BY: S L1� C. YEAR INSTALLED G)Pj�- 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. A• 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C.� UNLEADED F-]2 LEADED [:]3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL I ' PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN .R ❑ 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. #: xIII. 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 99 OTHER F-11 STEEL/IRON ❑ 2 STAINLESS STEEL FIBERGLASS F-14 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE E]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM [-]8 100% METHANOL COMPATIBLE FRP RECEIPT # ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A F-11 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING .lam1 6 UNLINED U 6 CONCRETE ❑ 95 UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP J21 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 U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER RECEIPT # A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A4R) 4 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 P S 1 VISUAL CHECK P 02 INVENTORY RECONCILIATION P S 3 VADOSE WELLS PO S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS o I 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 TANK ID # [nloTo-1�4 SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO APPR ED BY NA GALLONS I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTFD & IGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # = JURISDICTION # I I I i AGENCY # FACILITY ID # EI I I 119101115LI51 TANK ID # [nloTo-1�4 CURRENT LOCAL AGENCY FACILITY ID # APPR ED BY NA PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL D E P RMIT EiPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT.1 mw� FEE CODE 7 RECEIPT # j BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED Il.VWFACILITY/SITE APPLICATION, FORM 'A', UNLESS A CUIMNT FORM'A' HAS BEEN FILED DATA PROCESSING COPY No