COMPLIANCE INFO_1990-2003 - Laserfiche WebLink

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;.ST�4T� OF CALIFORN WATER RESOURCES CONTR OARD FORM BU r �o TANK TANK PERMIT 1 INFORMATION ® . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `"I.0 '" MARK ONLY ®1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PE RMI 6 TEMP RAFA NK CLOSURE ®8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED; Station-G !!cG- L i 1 FARM TANK-Y,E NO SballI. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A c, A. OWNERS TANK ID# UnknQwn B. MANUFACTURED BY: C.YEAR INSTALLED 1990 D. TANK CAPACITY IN GALLONS: 12 O O O 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A.161 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C• ❑ 1 UNLEADEDff:l LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL JET FUEL ®6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN 2 WASTE ❑7 METHANOL OT RSCRIBE IN ITEM D,BELOW) D.iF NOT MOTOR VEHICLE FUEL,ENTER NAME OF _mt;t:I v HAZARDOUS SUBSTANCE STORED&C.A.S.# Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN OX A, ,C,&D L A.TYPE OF 1 DOUBLE WALLED F__j 3 SINGLE WALLED WITH EXTERIOR LINER F-195 UNKNOWN ENVIRONMENTAL ALT SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS ®4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ®5 CONCRETE 0 6 POLYVINYLCHLORIDE -E]7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP [:]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 WI H 100%METHANOL? ®YES F NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE 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 Ar SYSTEM TYPE A U 1 SUCTION <0 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWNA 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 STAINLESSSTEEL 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 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS (P 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 FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES O 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 ENUMBER JURISDICTION# AGENCY# FACILITY ID# TANK ID# CY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE s PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: MEOW I FORM B(6-29-88) THIS FORM MUST BE ACCO BY A FACILITY/SITE APPLICATION, FORM`A',UNUNWRENT FORMA' HAS BEEN FILED PROCESSINGDATA