COMPLIANCE INFO_1986-1998 - Laserfiche WebLink

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I WATER RESOURCES CONTRO OARD 4..:. FORM `B'� UND ROUND STORAGE TANK PRO A TA TANK PERMIT APPLICATION INFORMATION ( �COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACFI TANK. C�i!iOPN;� MARK ONLY ❑1:NEW INTERIM IM PER Q 3 RENEWAL PERMIT ®5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO K I Q ONE ITEM p INTERIM PERMIT ❑4 AMENDED PERMIT ®6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2..Q SGP_vCC01 FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I CD CD A. OWNERS TANK ID q B. MANUFACTURED BY: -4 C.YEAR INSTALLED ' 00 D. TANK CAPACITY IN GALLONS: Q If. TANK 96NTENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL 0 2 PETROLEUMC. i UNLEADED E012 LEADED 3 DIESEL ®3 CHEMICAL PRODUCT, 4 OIL ;. , PRODUCT 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.Y C.A.S.M 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM El SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER B.TANK ❑i STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ®4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE El 6 POLYVINYL CHLORIDE M 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP El 9 BRONZE M 10 GALVANIZED STEEL M 95 UNKNOWN ®99 OTHER C.INTERIOR I RUBBER LINED ®2 ALKYD LINING ❑3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS UNINO ❑6 UNLINED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100 METHANOL? ❑YES ❑NO F]99 OTHER D.CORROSION ❑i POLYETHLENE WRAP ®2 TAR OR ASPHALT M 3 VINYL WRAP ®4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE 0 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 WALLED A 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) A U 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. LPPS 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L i.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED UANTITY OF SUBSTANCE REMAINING IN 3•WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YES NO THIS FOR"AS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTER)6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION Rt AGENCY N FACILITY I9D�I TANK ID# (/ 6 Lj� Ll CURRENT LOCAL A<ENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE® ? PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK Y PERMIT AMOUNT SURCHARGE AMT. ®`s` FEE CODE 9 � RECEIPT N SY:� FORM a(6 29-88) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM `A',UNLESS A NT FORMA' HAS BEEN FILED DATA PROCESSING COPY