COMPLIANCE INFO_1993-2002 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM V: UNDE&ROUND STORAGE TANK PRAM TANK TANK PERMIT APPLICATION INFORMATION :...� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMITCHANGE OF INFORMATION ❑7 PERMANENTLY CL T ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: j r FARM TANK-YES❑ NO L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY i A. OWNERS TANK ID# U B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C7) A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM S. 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&C.A.S.# C.A.S.#: xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 80X A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEMSING WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL F-13 RBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑'5'CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR rL=�J F-11 RUBBER LINED n 2,4d YD LINING ❑3 EPDXY LINING F-14 PHENOLIC LINING / LINING ❑5 GLASS UNING.' 6 UNLINED 95 UNKNOWN ❑ IS LONG MATERIAL COMPA11BLE WITH 100%METHANOL? ❑YES [::] NO ❑99 OTHER D.CORROSION ❑ 1 POLYET)IIENEWRAP U�91 OR'ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB4 GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION -A W2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED' A U 3 LINED TRENCH A V5 UNKNOWN A U 99 OTHER A U 1 STEEL/1 ON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OiH6 . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. / P VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3'4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS j✓� P 6 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 LISED(MO/YR) 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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 v f ' LOCAL AGENCY USE ONLY i f COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# i ® d4lTO 0 I CURRENT LOCAL AGENCY FACILITY 1 # APPROVED BY N;?_ PHONE#WITH AREA CODE ff 1 { PERMIT NUMBER PERMIT APPROV DATE RMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE MT. FEE CODE RECEIPT k BY: B G v FORM B(3-7-88) THIS FORM MUST BE ACCOM*-#YAFACILr"/Srm APPLICATION, FORM 'A',UNL W RENT FORMA' HAS BEEN FILED j DATA PROCESSING COPY