COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

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T 1 1 CWATER RESOURCES CONTRfARD g•'� ,'`�. FORM ' ' ROU DST RAGE TANK R �o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. {� I MARK ONLY 1 NEW PERMIT F-1U 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMArNENTLY CLOSED TANK ONE ITEM ®2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O FARM TANK-YES❑ NO rr 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# OS— B. MANUFACTURED BY: u C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11.:TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,.COMPLETE ITEM D. A. E2"' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C• [::] l UNLEADED E 2 LEADED DIESEL 3 CHEMICAL PRODUCT ❑4 OILU ' PRODUCT 4 GASAHOL ❑5'JET FUEL 6 AVIATION GAS El 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.# A.)ZAC.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A,B,C,&o A.TYPE OF DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ®99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE F-�6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F-�8100%METHANOL COMPATIBLE FRP MATERIAL ®9 BRONZE 10 GALVANIZED STEEL ®95 UNKNOWN ®99 OTHER ❑ 1 RUBBER LINED F-�2 A D LINING ❑3 EPDXY LINING ®4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING 6 UNLINED ®95 qNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP AR OR ASPHALT F-]3 VINYL WRAP ®4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION E.91 NONE 95 UNKNOWN 99 OTHER IV. PIPING INFORMAWN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE AW SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 1 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 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 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 DETECTIONSYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 616 P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P; S 6 PRECISION TESTING P a PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1.'INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ETI ATED DATE LAST USED(MO/YR) 2. ESTIMATED O NTITY OF 3.WAS TA K FILLED WITH / SUBSTAN E INING IN GALLONS IN T ERIAL? F-]YES ® NO ` THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Eff] I- I I I E ol 0 1112 1 i4' I I I d a El�l CUR ENT LOCAL AGEN1CY FACILITY ID# APPRO BY NA PHONE#WITH AREA CODE 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-86) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE APPLICATION, FOR 'A',UNLESS A RRENT FORMA' HAS BEEN FILED" DATA PROCESSING