COMPLIANCE INFO_1985-1992 - Laserfiche WebLink

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STATE OF CALIFORNIe . WATER RESOURCES CONTRcl OARD R FORI DERGROUND STORAGE TANK PROGRAM \a �fiNK PERMIT APPLICATION INFORMATION TA M 'E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O �rNMERPAL LTH 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK ITV§ERT uLqMIT El 4 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE [::]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: a,5-)57_ Co().l y 61-L)g FARM TANK-YES❑ NO ® O • 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# ,Say- 3 S)v - W(� B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: SSv 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F-1 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&C.A.S.# WA-ST/—c ��L C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER © 1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER C. INTERIOR 1 RUBBER LINED F-] 2 ALKYD LINING �3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING 5;�6 UNLINED ❑95 UNKNOWN E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [-] NO 99 OTHER D.CORROSION ❑ 1 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 U 2 PRESSURE A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 ©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 8 100%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 S 1 VISUAL CHECK 41162 INVENTORY RECONCILIATION P S 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 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 USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [-] NO THIS FORM HAS BEE OMPLETED 4PER42EAIALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. ACAE(PRINTED&SIGNA ) I DATE /urs �,eAl� Fu,2�;1 40A) S LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# m CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT LSURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEWY A FACILITYISITE APPLICATION, FORM`A',UNLESS A RENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY