COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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WPM= STATE OF CALIFORNI WATER RESOURCES CONTR OARD �F FORM `B': UND GROUND STORAGE TANK PRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ", I fib' MARK ONLY 1 NEW 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 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO CAa I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Q) A. OWNERS TANK ID# B. MANUFACTURED BY: r*0 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 006) II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. © 1 MOTOR VEHICLE FUEL ❑ 2 TROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED F-13 DIESEL F—] 3 CHEMICAL PRODUCT 4 OIL ❑ 1 PR DUCT ❑ 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.# 6'[2C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 OUBLE 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 CLADW/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 C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING F—]3 EPDXY LINING E]4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN [:] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO F'99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP LF-1 2 T -0R ASPHALT F—] 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 UNDERROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A 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 A6 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. ' r P S-1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS l/ P S" 6 PRECISIONTESTIN S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER 'BVI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMAT D QUANTITY OF 3,WAS 1,ANK FILLED WITH SU ST C EMAINING INE ERIAL? ❑YES [:] NO I'dGALLONS THIS FOR HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY FPFi-RkMlTFiL*BER JURISDICTION# AGENCY# FACILITY ID# TANK ID# 7-711 I EI I I I do I ! I I D G NCY FAC LITY D# APP O �BY NAME PHONE#WITH AREA CODE �,' "r �j PERMIT APPROV L DA PERMIT EXPI ATI N DATE PERMIT AMOUNT SURCHA GE AML J'FEECODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BEACCO A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY