COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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.z. . STATE OF CALIFORNO WATER RESOURCES CONTROARD yE,F f FORM `B': UNDERGROUND STORAGE TANK PROGRAM TA Alli TANK PERMIT APPLICATION INFORMATION CO LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. R MARK ONLY ErN1W PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION M-8- 7 PE NENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0657 h / Z Do� s� FARM TANK - YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: U% C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CGHTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.11. IS NOT MARKED. COMPLETE ITEM D. _ lul A. MOTOR VEHICLE FUEL ❑ 2 P ROLEUM ❑ 3 CHEMICAL PRODUCT OIL ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN B. P 0 UCT WASTE C. ❑ 1 UNLEADED - EADED ❑ 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # O C.A.S. : x111. 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 SYSTEMID SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP STEEL/IRON A ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 4 FIBERGLASS PIPE F-11 RUBBER LINED F-]2 ALKYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING EP-6'DNUNED A U 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A ❑ 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 Eplr-146NE ❑ 95 UNKNOWN ❑ 99 OTHER rIrn'17A 1 Iv171 GIHI Lt A Ir {it5VVt UNVUNU, U II- UNUtNk2NUUNU, ISU I M IF AYYLIUAtfLC A. SYSTEM TYPE A U 1 SUCTION A l FACILITY ID # Ld 0 -PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 01 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER PERMIT AMOUNT AU 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 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER I V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P4 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER I VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH l FACILITY ID # Ld 0 SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑ NO 1 GALLONS PHONE # WITH AREA CODE 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 # ELOCAjL JURISDICTION # AGENCY # El I I l FACILITY ID # Ld 0 TANK ID # L% SCURRAGENCY FACILITY ID # APPR VED BY NAME 13 PHONE # WITH AREA CODE PERMIT NUMBE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIfnY A FACILITY/SITE APPLICATION, FORM `A', UNLESS ATRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY