COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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,` STATE OF CALIFORN6 WATER RESOURCES CONTROARD FORM 'B': UNDE9GROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION.,; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED ol FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4 er' f ', FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # !w/� B. MANUFACTURED BY: fes, C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1.;Z ODO II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. aa -1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ©TPRODUCT ❑ 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. #: 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 SYSTEM ©2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 SINGLE WALLED A U 2 DOUBLE WALLED 211--STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 6 100% METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A U 8 100% METHANOL COMPATIBLE FRP 1 RUBBER LINED 2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED FEE CODE RECEIPT # 95 UNKNOWN BY: ❑ 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 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A Q95 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 C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U �U 9 GALVANIZED STEEL A 6) )95 UNKNOWN A U 99 OTHER SURCHARGE AMT. 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 VS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATT MONITORING WELLS P 0 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P M99 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 FACILITY ID # oC11H� SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO 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 # .3 JURISDICTION # AGENCY # FACILITY ID # oC11H� TANK ID # CURRENT LOCAL AGENCY FACILITY 1D # APPROVED BY NAME PHONE # WITH AREA CODE 6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAT a�a9 88 CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A', UNLESS A NT FORM'A' HAS BEEN FILED DATA PROCESSING COPY