SR0081919 - Laserfiche WebLink

Home Browse Search

' , -..."rrT'�'z^'�ST"i�;�,, *'c.'-i-, -7^ i �.-:��,.�1r'°y*P'Ik`:if�.{.;��.. .�... ,+:-fit - - . _.�q"-•" ' STATE OF CALIFORN" WATER RESOURCES CONTRO"RD "^r;• FORM W: UNDERGROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIr INFORMATION FOR EACH TANK. , !c� MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSFD TANK ONE ITEM n 2 INTERIM PERMIT 4 AMENDED PERMIT Ll 6 TEMPORARY TANK CLOSURE n 8 TANK REMOVED �^ CA1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Qj&eh FARM TANK-YES NO f-A 0D I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 00 A. OWNERS TANK 10 R 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 F1 2 PETROLEUM B C u l UNLEADED D 2 LEADED U 3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL LJ 1 PRODUCT 1:1 4 GASAHOL LA 5 JET FUEL n 6 AVIATION GAS El 5 HAZARDOUS 0 80 EMPTY [:]95 UNKNOWN n 2 WASTE 07 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. If NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C A.S R CAS R. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF U I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER E]95 UNKNOWN SYSTEM 0 2 SINGLE WALLED �4 SECONOARYCONTAINMFNT �99 OTHER I STEELPRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK 0 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP MATERIAL 4 BRONZE U 10 GALVANIZED STEEL F]95 UNKNOWN L]99 OTHER 1 RUBBERLINED 2 ALKYO LINING 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING ��6 UNLINED �95 UNKNOWN IS LINING MATERIAL COMPATIBLEWITHIW%METHANOL? F]YES [:]NO 09 OTHER D.CORROSION I POLYETHLENE WRAP F]2 TAR OR ASPHALT u 3 VNYLWRAP 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 AU I STICTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I 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 I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE JPVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCREIE A U 7 STFELCLADW/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 I VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 EI FCTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURL I LSIING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER - VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 7MAT ED DATE[AST USED(MO/YR) 2 ESTIMATED OUANTIIY OF 3 WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIALS YES NO --- - THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 6 SIGNAL URI:) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID N TANK ID R 1010 lo I CURRENT LOCAL AON FACILITY ID R APPROVED BY NAME PHONE V WITH AREA CODE _els-�� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRA ION DATE I I CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 1 BY: U FORM n(6 29 88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED nArA nn^nrcowu n^nv