COMPLIANCE INFO_1986-1998 - Laserfiche WebLink

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STATE OF CI,lr NI WATER RESOURCES CONTRO ARD7�a y �3S - FOR DE ROUN6 STORAGE TANK PRO AM > o ANK PERMIT APPLICATION INFORMATION TA M pV p SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. M&WARW Al EWAE - ^�TH ❑3 RENEWAL PERMIT Z-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY T NK ONE I [�A'IV'T5E;R W YEE6RMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV a FACILITY/SITE NAME WHERE TANK IS INSTALLED: r,,Vl OIL- 1 FARM TANK-YES I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY • A. OWNERS TANK ID# `1 S-aL/-(t3!5-y-JC IJ-1 B. MANUFACTURED BY: Ow E S Co2^11t-)[7 �J C. YEAR INSTALLED g 9 D. TANK CAPACITY IN GALLONS: / o(-) II. TANK CONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Cat A. [�4 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. Liji 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL ® 1 PRODUCT E]4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS [-]5 HAZARDOUS ❑80 EMPTY E]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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF 4 F!C] 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-] 1 STEEL/IRON ❑2 STAINLESS STEEL 10 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-]5 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑8 100%METHANOLCOMPATIBLE FRP 4 ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER 4 C. INTERIOR F-] 1 RUBBER LINED ❑ 2 ALKYD LINING F-]3 EPDXY LINING E:]4 PHENOLIC LINING LINING ❑ 5 GLASS LINING �6 UNLINED 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 2 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© 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® 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 16 S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING 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? F-]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER P NALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT' #E(PRINTID&SIGNATUR DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [:H I I I ] [:[ i i LL 111olorl I I T 1 ,ri CURRENT LOCAL AGENCY FACILITY ID# ,p APPROVED BY NAME PHONE#WITH AREA CODE (.'e PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT AWL I SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY