COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

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STATE OF CALIFORKILAL WATER RESOURCES CONT OARD sE...............r. FORM 'B': UND GROUND STORAGE TANK PR -RAM io TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z: CO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n 7RnMANENTLY CL05FDJANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE Ep 88 TANK REMOVED /+1 V N FACILITY/SITE NAME WHERE TANK IS INSTALLED: C A-Alg LO OU i M FARM TANK-YES❑ NO *11. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C�'1 A. OWNERS TANK ID# 43 B. MANUFACTURED BY: Pptzs✓i/�15 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 1.000 II. TANK CONTENTS IF(A.1) MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL �1PRODUCT ❑ 4 GASAHOL [:]V510TFUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOLHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF �7 HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 3 I� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D fI A.TYPE OFDOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-]95 UNKNOWN SYSTEM 2 GLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER I j 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC I B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP t ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER t ❑ C. INTERIOR 1 RUBBER LINED ElLKYD LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 OWN/ U ❑ IS LINING MATERIAL COMPATIBLE WITH 0%METHANOL? ❑YES [:] A NO 99 OTHER 1 "' E 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC I D.CORROSION ❑ ❑ ❑ PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFA GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 B.CONSTRUCTION A nU f 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 �CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP P' A U 9 GALVAN I ZED STEEL A �J 5 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. R' P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �v 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 SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONS 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# F�M I i I ] [:I I I I r� lFn o i CURRENT LOCAL AGENC ACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE i r PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ` CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FO RM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY