COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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777 LdL STATE OFAC;"ALIFORN WATER RESOURCES CONTR OARD STOR AFOR ` ': PGROUND P g °• _� w� TANK TANK PERMIT APPLICATION INFORMATION ® , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. �^ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS NK ONE ITEM ❑2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED f FACILITY/SITE NAME WHERE TANK IS IN FARM 1 FARM TANK-YES❑ NO ,Eg 00 1 TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A:OWNERS TANK ID# B. MANUFACTURED BY: UF C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF .1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL2 PETROLEUM B. C. ❑ 1 UNLEADED E] 2 LEADED ❑3 DIESEL L-i❑3 CHEMICALPRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 514 FUEL ❑6 AVIATION GAS 5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ®7 METHANOL Gzr99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# Si Mel C.A.S.It: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A,B,C,&D A.TYPE OF ❑ DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ®99 OTHER 1 ST€ELIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE V91 MINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ®2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED k99 NKNOWN 1S LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NOTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAgION CIRCLE A'IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 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&195 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 U''95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEMCIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P' S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P $ 91 NONE P $ 95 UNKNOWN P S 99 OTHER VI. INFORMATION 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 F-] 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# EE I I a'l I I / If& I /] Do lo CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: AOL FORM B`(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM IN,UNLESS AIRENT FORMA' HAS BEEN FILED DATA PROCESSING ,,