COMPLIANCE INFO_1987-2002 - Laserfiche WebLink

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STATE OFCALIFORN ATE CES T ARD 'h� T A F ' ': UN ROUND STORAGE TANK PROGRAM �o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. DWG I MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ®5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM El 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED Q t FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY LCYO WNERS TANK ID# B. MANUFACTURED BY:EAR INSTALLED D. TANK CAPACITY IN GALLONS: Woo 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,C MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C• Yl UNLEADED ❑2 LEADED F--]3 DIESEL 3 CHEMICAL PRODUCT � 4 OIL 1 PRODUCT ®4 GASAHOL 5 JET FUEL F-�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.#: I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A,B,C, D A TYPE OF ET1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ®4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON' ❑2 STAINLESS STEEL I NA 3 FIBERGLASS F-�4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F-16 POLYVINYL CHLORIDE F--j 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL [:]95 UNKNOWN 99 OTHER C.INTERIOR i RUBBER LINED F-12 ALKYD LINING ®3 EPDXY LINING F-]4 PHENOLIC LINING LINING ❑5 GLASS LINING 2-6—UNLINED 0 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ® NO 99 OTHER D.CORROSION` ❑ 1 POLYETHLENE WRAP F-1 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 AU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER IL CONSTRUCTION A U 1 SINGLE WALLED A(U3 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&1 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 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS©S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 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 NIA GALLONS SUBSTANCE REMAINING IN 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I 1 11 1 1 F F71 CURRENT LOCAL AGENCY FACILITY 1®# „ APPR VED BY NAME J PHONE#WITH AREA CODE ve 2 S � PER IT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE j CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B'(6-29-88) THIS FORM MUST BE WCOMPANIMP ,A F4611.1111f/SITEAPPLICATioN, FORM` ',UNLESS A RENT FORM`A' NAS BEEN FILED DATA PROCESSING Y