COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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STAVE OF CALIFOR'N WATER RESOURCES CONTR OARD S FOR V: UND GROUND STORAGE TANK PRO RAM _ ao TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A'SEPARATE FORM WITH THE FOLLOW10 INFORMATION FOR EACH TANK. 1 MARK ONLY ❑1 NEW PERMIT ®3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ®7 PERMANENTLY CLO NK ONE ITEM ®2 INTERIM PERMIT ®4 AMENDED PERMIT ®6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 9® A FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED 1 D. TANK CAPACITY IN GALLONS: II. TAN NTENTSIF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. r 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ® 1 UNLEADED 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL EV1 PRODUCT ❑4 GASAHOL 5 JET FUEL F-] 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY [-]95 UNKNOWN ❑2 WASTE E]7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D.;IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY/N sox A,B,C,&D A.TYPE OF ❑ 1 UBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM2 SINGLE WALLED E]4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON F-1 2 STAINLESS STEEL ❑,,3 FIBERGLASS ®4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE -17 ALUMINUM ®8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ®99 OTHER ® C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ® 3 EPDXY LINING V95 HENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ®99 OTHER D.CORROSION ❑ 1 POLYEIHLENE WRAP ❑2 TARORASPHALT F-� INYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC Fiif 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 A14 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER V. LEAK DETECTIOMYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. $ `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 S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION O 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? F-1YES ❑ 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 COUNTY#' JURISDICTION# AGENCY# FACILITY ID# TANK ID# I ol ol 7 I F�Fol o 12,1 CURRENT LOCAL AGENCY FACILITY ID# C APPROVED BY NAME PHONE#.WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B`(6-29-s8) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM`A',UNLESS A PMENT FORMA' HAS BEEN FILED PROCESSINGDATA