COMPLIANCE INFO_1985-1993 - Laserfiche WebLink

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STATE OF CALIFORN116 WATER RESOURCES CONTR OARD W. FORM `B': UNDERGROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 5 CHANGE OF INFORMATION E]7 PERMANENTLY CLOSED TANK ONE ITEM F-1 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE F-]8 TANK REMOVED , FACILITY/SITE NAME WHERE TANK IS INSTALLED: '3415 , FARM TANK-YES❑ NO f f` Eg- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 3' A. OWNERS TANK ID# Q^'(p 7 a 5 k a B. MANUFACTURED BY: u,K �I C. YEAR INSTALLED i D. TANK CAPACITY IN GALLONS: DOD 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 F--] 2 PETROLEUM B. C. [:] 1 UNLEADED [:] 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT F-1 4 OIL R/ ,'PRODUCT 0 4 GASAHOL D 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.#: xIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 0 99 OTHER 'STEEL/IRON E]2 STAINLESS STEEL F-] 3 FIBERGLASS F-] 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE E] 6 POLYVINYLCHLORIDE 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER F-]C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING LINING F-] 5 GLASS LINING El 6 UNLINED ©95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES 0 NO 99 OTHER FCC RROSION ❑ 1 POLYETHLENE WRAP /��2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC OTECTION 5 CATHODIC PROTECTION D 91 NONE -W95 UNKNOWN D 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A(U�> SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 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) A U 4 FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN CI 99 OTHER Wn 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 0 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 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. 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 BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY FCOUNTY# JURISDICTION# AGENCY# FA/CILITY ID# TANK ID# FI E I 10 10 1 LL 7-1 Lo I 0 A CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA!Igt PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANININ A FACILITY/SITE APPLICATION, FORM`A',UNLESS A RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY