COMPLIANCE INFO_1985-2003 - Laserfiche WebLink

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0 .:.. �. - � r.. ,>; .,..,� ,.�mvr�,.�„Ar'.'. PiP^vYt + !''i ; il{ ..- n ,n„��7 ^y''.�' Y rP'*.vr:,• . STATE OF CALIFORNWATER RESOURCES CONTR OARD yNF FORM V: UND' GROUND STORAGE TANK P RAM a'm 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 / - FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6 �� e S f FARM TANK - YES ❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # u, K B. MANUFACTURED BY: C. YEAR INSTALLED 644D. TANK CAPACITY IN GALLONS: 00 II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL B. I v l ' PRODUCT C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 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. #: xlll. 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 Ee �2SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL F-1 3 FIBERGLASS F-] 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 F-11 RUBBER LINED 2 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 6 CONCRETE 95 UNKNOWN U ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT F] 3 VINYL WRAP F-] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-] 5 CATHODIC PROTECTION ❑ 91 NONE Fp 95 UNKNOWN E] 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND. BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ACJU 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 Q 95 UNKNOWN A U 99 OTHER PERMIT EXPIRATION DATE 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A QU 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 SS 1 VISUAL CHECK ® S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 1 a2 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN n 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 FACILITY ID # 1.� C yl SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYY # / JURISDICTION # AGENCY # FACILITY ID # 1.� C yl TANK ID # Lo T09� CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAMBffl PHONE # WITH AREA CODE ol I la 610e PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE • CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # K BY: �l FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED 'bMK FACILITY/SITE APPLICATION, FORM `A', UNIESSIMMI41T FORMA' HAS BEEN FILED DATA PROCESSING COPY