COMPLIANCE INFO_1985-1992 - Laserfiche WebLink

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: P n.: 3 i <r,, :1.':M t�i1. .• r..., rj:Y PrKrr 9 jr. .., •.'e7 a:. .. t:.... STATE OF CALIF I WATER RESOURCES CONTRO690ARD FORM B': UND ROUND STORAGE TANK PRO A TANKTANK PERMIT APPLICATION INFORMATION 7� COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 FORMATION FOR EACH TANK. ".o ,P MARK ONLY 1 PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z-5 j54ARM TANK-YES❑ NO LJ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [21 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED [211 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL al PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS d ❑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.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF Efr 1DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON F-12 STAINLESS STEEL [D-3FIBERGLASSF-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ®7 ALUMINUM F-18 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED Fl2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING EitfuNUNED ff95 UNKNOWN ® IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES !0 ❑99 OTHER D.CORROSION ❑ I POLYETNLENE 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 PRESSURE A U 3 GRAVITY A U 99 OTHER B,CONSTRUCTION A U 1 SINGLE WALLED A DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) FIBERGLASS PIPE 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. TIN 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELL 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER FORMATI ON TANK PERMANENTLY CLOSED IN PLACE AT TE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES F-1No. THIS FORM HAS BEEN CO ETL-94JNDER PENALTY OF PE RY, ND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLIC ;MRI-NT-q' ),lCSIGNATURE) DATE A--/lef c zs=- LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � I I I J- - EI I I f F71 I I I Iq I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE Ize7vv PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATI ATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPA v dY A FACILITV/SITE APPLICATION, FORM`A',UNLE „QRENT FORM'A' NAS BEEN FILED nATA AROCFCCINr r"nnv