COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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STATE OF CALIFORN WATER RESOURCES CONTR OARD g•'..::, r. a FORM `B': UND .GROUND STORAGE TANK PRO RAM �o TANK G TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ^� O i'P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE NN ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED o i FACILITY/SITE NAME WHERE TANK IS INSTALLED: &12 FARM TANK - YES O I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLO : II. TANK CONTENTS IF (A.11. IS MARKED. COMPLETE ITEM C. IF (A.1). IS NOT MARKED. COMPLETE ITEM D. / A. OFl MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED [:]2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL Y� 1 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. # C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D IV. A. TYPE OF 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LIN R ❑ 95 UNKNOWN SYSTEM ❑ VNGLEWALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER PRESSURE 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U F-11 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED C. MATERIAL 95 UNKNOWN 5 ALUMINUM ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ THER 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 rlr119%9 119r%JnMf41 IWM L;IHL;Lt A IF 2. ESTIMATED QUANTITY OF UHUUNU, U IF UNUtHUHUUINU, MUTH IF APPLIGA6LE TANK ID # A. SYSTEM TYPE A54 1 SUCTION A U PRESSURE APPROVED BY NAME 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION SINGLE WALLED A U 2 DOUBLE WALLED AU PERMIT APPROVAL DATE LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) U ERGLASS 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 SECOND9ex, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. IP S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WE S P ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I 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 TANK ID # SUBSTANCE REMAINING IN INERT MATERIAL? YES NO 1 111/ GALLONS CURRENT LOCAL AGENCY FACILITY ID # 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 # 111/ 1167 CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE /V�4131 PERMIT NUMBER PERMIT APPROVAL DATE PE IT EX ATION DATE tM � CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT # BY: FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, F V HM 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY