COMPLIANCE INFO_1989-2008 - Laserfiche WebLink

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$�" c ,'*+sex ��-�� g<x ew�s^.•aa�naraw* .-�„xm, {r*s '*�Y al TE CSF CALIFORN WATER RESOURCES CONTRA&BOARDFORMV: UND GROUND STORAGE TANK z o TANK TANK PERMIT APPLICATION INFORMATION MPL&E A S OARATE FORM WITH THE FOLLOWING INFORMATION FOR EACFI-TANK.: 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 FACILITY/SITE NAME WHERE TANK IS INSTALLED: fL ° I L.. FARM TANK-YES❑ NO 1 TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q H. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 0 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. �• � 1 UNLEADED r-12 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ®4 GASAHOL ❑5 JET FUEL Ej 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.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEELTA 3 FIBERGLASS F-1 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ®5 CONCRETE F-�6 POLYVINYLCHLORIDE ®7 ALUMINUM ®8 10096 METHANOL COMPATIBLE FRP MATERIAL. 9 BRONZE ®10 GALVANIZED STEEL ®95 UNKNOWN ❑99 OTHER C.INTERIOR ❑1 RUBBER LINED ❑2 ALKYD LINING ❑'3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNUNED ❑95 UNKNOWN ®IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑'1 POLYETHLENE WRAP ❑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 A :U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLEDA 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) AQ 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 0S 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 PENAL F PER R ,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE L. AL'S uc.-c► l(0 1 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION'# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY 1 # DYED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPAN Y AMLnymn AppucATioK FOR `A',UNLESIS IRREI FORMA' HAS BEEN FILED T PROCESSING -Y