BILLING 1985 - 1993 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN WATER RESOURCES CONTRTOARD e FORM W: UNDE GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED owy FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1161 /r, - FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY PO A. OWNERS TANK ID R C/ B. MANUFACTURED BY: NK , W C.YEAR INSTALLED N K- D. TANK CAPACITY IN GALLONS: /Q QUp (rAP(L 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. O C)C A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8. C. E21 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ /OIL ❑l PRODUCT ❑ d GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑SO 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 6 C.A.S.R C.A.S.Y: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,6 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SNGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 mom ❑6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEELF?rq�5UNKNOWN ❑99 OTHER ❑ F INTERIOR I RUBBER LINED ❑ 2 ALKYD LINING F-1 OXY LINING 3 EP ❑1 PHENOUCUNINO � LINING ❑5 GLASSUNING ❑6 UNUNED U 5U UNKNOWN ❑ LS UNING MATERIAL COMPATIBLE WITH 100%METHANDL7 ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 295 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A W2 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 AeS795 UNKNOWN A U 99 OTHER A LA I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLWINYL CHLORIDE(PVC) A U I 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 B IDD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A NKNOWN 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 8 1 VISUAL CHECK o 8 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P S A ELECTRONIC MONITOR P 8 5 GROUND WATfF)MONITORING WELLS P8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P J06 99 OTHER 041 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED LMO/YR) 2. ESTIMATED OUANTITY OF - 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE L LOCAL AGENCY USE ONLY COUNTY# JURISDICTION� AGENCY Y FACILITY IDR TANK ID Y 3 E o l l 8 T1 o o o Z CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE R WITH AREA CODE 5#4u6- 60 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK( PERMIT AMOUNT $"-CHARGE AMT. FEE CODE RE 'T I By.. B 16-29 BB) E.T THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSINY: Y;OPY