COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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f STATEI WATER RESouRCEs coNTR ARD st. .. rh ii ` ' N ROUND STAG ;TA PRO A _ - TANK TANK PERMIT APPLICATION INFORMATIONm COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 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 FACILITY/SITE NAME WHERE TANK IS INSTALLED: / S FARM TANK-YES NO El 1 TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY EDA. OWNERS TANK ID# B. MANUFACTURED BY: W� 73- 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 Ej 5 HAZARDOUS ❑80 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.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,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 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS ®4 STEEL CLADW/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 ® 1 RUBBER LINED D 2 ALKYD LINING F�3 EPDXY LINING V95 ENOLIC LINING C.INTERIOR LINING ❑5 GLASS LINING F-16 UNLINED NKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES El NO [:1 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 YINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION ®91 NONE 95 UNKNOWN E]99 OTHER IV. PIPING'I 'FOR ATIO ` 'CIRCLE"A IF`ABOVE GROUND,U'IF UNDERGROUND,BOTH IF APPLICABLE- A.SYSTEM TYPEA 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 U 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 U 4 FIBERGLASS PIPE A U 91 NONE 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 J95 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. S 1 VISUAL CHECK f P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MON ITORING WELLS kp)S-6 PRECISION TESTIN 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 INGALLONS INERT MATERIAL? YES ® NO 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) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# u T 0 /1�1 01 It CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE 6 PERMIT NUMBER' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE --7 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE JaECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPAOMY A FACILITY/SITE APPLICATION, FOR 'A' UNLESS A RENT FORMA' HAS BEEN FILED PROCESSINGDATA