COMPLIANCE INFO_1984-1994 - Laserfiche WebLink

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STATE OF CALIFORNI WATER RESOURCES CONTR ARD 5." •° hf F ` : UNDERGROUND R o TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. oar 'I MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT E1115"CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ®6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 00 I." TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY EE TANK ID# ' / B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: - 11. TANK 9ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CQMPLETE ITEM D. A. Pl MOTOR VEHICLE FUEL _❑ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED ® 3 DIESEL ®3 CHEMICAL PRODUCT F-] 4 OIL ED4 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.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,13,C,&D A.TYPE OF F-� 1 DOUBLE WALLED F--j 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT D 99 OTHER STEEUIRON El 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ®6 POLYVINYLCHLORIDE ® 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ®10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER RUBBERLINED WUNUNED D LINING Q3 EPDXY LINING 4 PHENOLIC LINING LINING C.INTERIOR 5 GLASS LINING 17195 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 1 W%METHANOL? 0 YES ® NO ❑99 OTHER D.CORROSION ❑ 1,POLYETHLENE WRAP@'91TONCNE 2 OR ASPHALT ®3 VINYL WRAP ®4 FIBERGLASS REINFORCED PLASTIC PROTECTION ®5 CATHODIC PROTECTION ❑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 X72 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 a 95 UNKNOWN A U 99OTHER 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 1095 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 $ i VISUAL-0HECK OS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WAT7 MONITORING WELLS P $ 6 PRECISION TESTING P S '7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P&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? DYES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLtCANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK 1D# ITS-] GURRE �OCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE I , PERMI UMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHEGIC# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIE®BY A FACILITY/SITE APPLICATION, FORM` `,'UNLESS hM,RRENT FORMA' HAS BEEN FILED T -ING COPY -