BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORK A WATER RESOURCES CONTRC ,OARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM -TANK TANK PERMIT APPLICATION I FORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. MARK ONLY i*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 18 INSTALLED: ARCO FacilitV #6020 FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK IDM 4 B. MANUFACTURED BY:Xerxes C.YEAR INSTALLED DQQJ . TANK CAPACITY IN GALLONS: 10,000 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A.JZ] 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 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 6 C.A.S.It C.A.S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A.TYPE OF I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING E]3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN LINING ❑ ❑ ❑ tfl IS LINING MATERIAL COMPATIBLE WITH 100x METHANOL? ®YES ❑NO ❑99 OTHER D.CORROSION ❑ I 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 A.SYSTEM TYPE A U 1 SUCTION A&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 CQ 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) AUO 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 1OD%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 f 1 VISUAL CHECK P �f 2 INVENTORY RECONCILIATION P f 3 VADOSE WELLS ► ELECTRONIC MONITOR P f 5 GROUND WATER MONITOJackRING W1�LLS LD P f 6 PRECISION TESTING P f 7 PRESSURE TESTING P f 91 NONE P f 95 UNKNOWN P f 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 N/A SUBSTANCE REMAINING IN Nl� GALLONS INERT MATERIAL? /A F-1YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLI I;N7 BSIGNAT ) Frances W. Hedrick DATE A ent for ARCO 10-4- LOCAL AGENCY USE ONLY Barghausen Consulting Engineers, Inc. (916) 348-3057 COUNTYpf JURISDICTION N AGENCY#-- FACILITY ID f TANK ID f CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE 1 WITH AREA CODE Q� PERMIT NUMSER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK F PERYR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• my: FORM B(6.29.66) THIS FORM MUST N SY A FAulTY/SfTE AIwR9►flDN, FORM`A',UNLEp RNW'A' IMS LEEN TILED 1�OCESSING COPY 8 EpCAL AGENCY Car COPY