COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

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.-.,q^s-^ar-'xvs?..r•n-.7Tir:7-- vrT;,-�T,+."y�r'T.�n ,...a- -"�+�•- m.*c.r . ^,'?" —T—w— -17 STATE OF CALIFORNIAWATER RESOURCES CONTR OARD FORM `B': NDPGROUNDSTORAGETANKPROWRAM U WANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. C�iPo N P MARK ONLY F-] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY C ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �z6s-6 4 tv v FARM TANK-YES NO / I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPE IFY M A. OWNERS TANK ID# ® ? I B. MANUFACTURED BY: l` C. YEAR INSTALLED l D. TANK CAPACITY IN GALLONS: �U 6 U f II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D.",- A. .A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT F-14 OIL PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS C ❑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.#: z2A x111. TANK CONSTRUCTION MARK ONE IT M 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 i ❑ 1 STEEL/IRON 2 STAINLESS STEEL [:j 3 FIBERGLASS ❑4 TEELCLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F-16 POLYVINYLCHLORIDE F-] 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP tMATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YESElNO F-199 OTHER f D.CORROSION ❑ 1 POLYEfHLENE WRAP ❑2 TAR OR ASPHALT F-13 VINYL WRAP a�f4 FIBERGLASS REINFORCED PLASTIC iPROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AElpyE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U,1 SUCTION A (ti)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A 1 SINGLE WALLED A V 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 �UU� 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A V 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SY TEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. I I P S 1 VISUAL CHECK P 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 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER j VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LA T USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES ❑ NO I THIS F04A i H kq BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. f APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY f f COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# I E[ z- CURRENT LOCAL AGENCY FACILITYYIRDA, APPRO ED BYPAE PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM `A',UNLE8b A RRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY �jf.