COMPLIANCE INFO_1986-1989 - Laserfiche WebLink

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STATE OFCALIFORNIjk WATER RESOURCES CONTROJWARD .�.., FOR V: U D ROUNDSTORAGETANKPROaRAMnm+ TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 9f5 CHANGE OF INFORMATION ®7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED 1:5- FACILITY/SITE NAME WHERE TANK IS INSTALLED- p FARM TANK-YES❑ NO IV 1. TANK DESCRIPTION COMPLETE ALL ITE -IF UNKNOWN-SO SPECIFY —1 A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: oco 11. TANK CONTENTS IF(A.9,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ® 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑1 UNLEADED ®2 LEADED 3 DIESEL ®3 CHEMICAL PRODUCT ®4 OIL1 PRODUCT ®4 GASAHOL ❑ 5 JET FUEL F-16 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&C.A.S.N C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,8,C,&D A.TYPE OF -i DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ®2 SINE WALLED ❑4 SECONDARY CONTAINMENT ®99 OTHER 1 STEH./ION ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MR CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ®5 CONCRETE ®6 POLYVINYL CHLORIDE ❑7 ALUMINUM 8 100% COMPATIBLE FRP MATERIAL 9 BRONZE ®10 GALVANIZE)STEEL ®95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ®2 ALLINING ®3 EPDXY UNING 4 PWMUC LINING C.LINING KYD 5 GLASS LINING ®6 UNJNED ❑95 ® IS LINING MATERIAL CObPATIBLE WITH 1 ? ®YES ®NO ❑99 OTHER D.CORROSION a i POLYETHLENE WRAP ®2 TAR OR ASRHALT ®3 VINYL WRAP ®4 FIBERGLASS REI PLASTIC PROTECTION ®5 CATHODIC PROTECTION ®91 NONE ®95UNKNOWN ®99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A.SYSTEM TYPE A 1 SUCTION A U 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 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 STAINLESS STEEL 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 8100%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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WEII P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P B S 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 TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ® NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGiENCY# FACILITY ID# TANK ID# [iFzl I L-L-t-1 1 .1 1,513 - 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL.DATE PERMIT EXPIRATION DATE CHECK# FERM14 AMOUNT SURCHARGE AMT. FEE CODERECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE AN A FACK.IIY/SITE ICATION, FORM`A°,UN ENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY