COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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-7 1 *i L Y`C R.',.Ppm TR^'"'.". t. _ ,.,Ay4y�..s,p� y�'�iy,••pr".R'"m`_� STATE OF CALIFORNWATER RESOURCES CONTRI&OARD FORM 'B': UNDER GOUND R R``' STORAGE TANK PRAM�. TANK TANK PERMIT APPLICATION INFORMATION ' ' N � w m CO PLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. ~'=' MARK ONLY OWNEW PERMIT ❑ 3 RENEWAL PERMIT Pj'r5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS NK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED P) FACILITY/SITE NAME WHERE TANK IS INSTALLED: '4i S7,- t FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C.1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 49? ' 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, & D A. TYPE OF lff2l:� DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN A U 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-]5 CONCRETE F-]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F7]8 100% METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 2 STAINLESS STEEL F-]1 RUBBER LINED El2 ALKYD LINING F--]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED U ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES 00 ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 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 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 RECEIPT # 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: 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTIN20S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI ATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH FACILITY ID # SUBSTANCE REMAINING IN INERT MATERIAL? [::]YES ❑ NO I I I --] GALLONS I / THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. LOCAL Al APPLICANT'S NAME (PRINTED R SIGNATURE) ' DA� x �-0 IENCY USE ONLY FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A OGRRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY JURISDICTION # AGENCY# FACILITY ID # TANK ID # = I I I --] I=i I AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE E PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT J.SURCHARGE AMT. FEE CODE RECEIPT # BY: g� G' V FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A', UNLESS A OGRRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY