COMPLIANCE INFO_1986-2003 - Laserfiche WebLink

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< iFlit wpwpwWrr STATE OF CALIFORNISp WATER RESOURCES CONTRCWARD SE�t'uur;rE. FORM V: UNDE GROUND STORAGE TANK PRO AM o TANK TANK PERMIT APPLICATION INFORMATION ` COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 FORMATION FOR EACH TANK. 1 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ff7f5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS _TPNK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# JjDo I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GA NS: 8�b 11. 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 PETROLEUMB. C [:] 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT ❑4 GASAHOL F-] 5 JET FUEL ❑ 6 AVIATION GAS [:] 5 HAZARDOUS 0 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 1 DOUBLE WALLED F-� 3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 0TH ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL F-] 95 UNKNOWN E] 99 OTHER C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING El 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED [:] 95 UNKNOWN ❑ 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 E] 91 NONE 1:1 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 A 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 Aj(U�b 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(g24 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 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 P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST US D(MO/YR) 2. ESTIMATED O ANTITY OF 3,WA TANK FILLED WITH SUBST; C AINING IN I GALLONS MATERIAL? YES [:] NO 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# CURRENT LOCAL AGENCY FAC TY ID# APPROVED BY NA J HONE#WITH AREA CODE /vU gi� J n °\ PERMIT NUMBER PERMIT APPROVAL DATE PERMI.EXPIRATIQ CHECK# PERMIT AMOUNT Is,URCHARGE AMT. FEE CODE I RgtEI Tiy- FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORM';' HAS BEEN FILED DATA PROCESSING COPY.