COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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.r _;. :: �-•wry„-,....ryas-.--•"'+fir. ,,, ... ,-.,,... ,. T.Reye.p�„�lwl�,ti�.-r-,,,rr,y,�,,.,,��.a,�..,�...c�.. :+p ,..�-4...:, STATE OF CALIFORN WATER RESOURCES CONTRgbOARD FORM `B': UND GROUND STORAGE TANK PR RAM G o TANK TANK PERMIT APPLICATION FORMATION x COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. MARK ONLYNEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I FACILITY/SITE NAME WHERE TANK IS INSTALLED: &? � !f/Y �/ ,ST_ FARM TANK - YES ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLEDD. TANK CAPACITY IN GALLONS: Il. 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 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL iR51PRODUCT ❑ 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. #: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. CONSTRUCTION ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS. 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC �❑ B. TANK F-]5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM �� 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE F-]1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C NINTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ 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 MPRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION U 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& 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/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 S ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISIONTESTINClP 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. ESTIM TED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH NKID# T= SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES [:]NO I El I I LL I I I i-1 GALLONS AGENCY FACILITY ID # THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. LOCAL AI APPLICANTS NAME (PRINTED & SIGNATURE) DATE r� IENCY LISE ONLY FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED- A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AZ'EiiRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY JURISDICTION # AGENCY# FACILITY ID # NKID# T= I I I I El I I LL I I I i-1 I o I ppA�� V To -77-1 AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE E PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: J FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED- A FACILITY/SITE APPLICATION, FORM 'A', UNLESS AZ'EiiRENT FORM `A' HAS BEEN FILED DATA PROCESSING COPY