COMPLIANCE INFO_1996-2002 - Laserfiche WebLink

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STATE OF CALIFORW WATER RESOURCES CONTBOARD ism.°:,'N• i FORM `B': UNDERGROUND STORAGE TANK PROGRAM =� o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT U&-15HANGE OF INFORMATION ❑ 7 PERMANENTLY CL 11 B1 �t ONE ITEM 1:12 INTERIM PERMIT ❑4 AMENDED PERMIT F-16 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO Fr I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cn A. OWNERS TANK ID# CAll B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C 1 UNLEADED ❑ 2 LEADED F-13 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 21",,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 I HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN I SYSTEM R2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-] 1 RUBBER LINED ❑2 AL LINING F-] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ffT-6 UNLINED ❑ 95 UNKNOWN, ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO9 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP �TAR OR ❑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 4 A.SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 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 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 0)6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL All 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P ft 1 VISUAL CHECK ZPrS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS y S' 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. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATEq QUANTITY OF 3.WAS T NK FILLED WITH SUBSTA EMAINING IN I GALLONS ER AERIAL? ❑YES [-] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY JPE UNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# � � 1 � � �To .� LOCAL AGENCY F�II ITY ID# APPRO ED X NAME ^ PHONE#WITH AREA CODE UMBER PERMIT APPROVAL DATE PERMIT E PIRA ION D E PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM MUST BE ACCOMPANIE FACILITY/SITE APPLICATION, FORM `A',UNLESS APWRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY