COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

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lw IR , t C .. ' ., v s.-`•:0. ,'i r a. q - STATE OF CALIFORNI WATER RESOURCES CONTR OARD FORM `B': UNDERGROUND STORAGE TANK PROGRAM - o TANK TANK PERMIT APPLICATION INFORMATION �< COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. so MARK ONLY 25'1' NEW PERMIT F] 3 RENEWAL PERMIT F-] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED V/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: l b �t1�/v -� FARM TANK-YES❑ NORr Co I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# Q B. MANUFACTURED BY: C. YEAR INSTALLED 1174,1D. TANK CAPACITY IN GALLONS: 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 P PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL F-] 3 CHEMICAL P4 OIL RODUCT 1 PRODUCT ❑ 4 GASAHOL ❑e99 T FUEL 6 AVIATION GAS E] 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN 2 WASTE El METHANOL THER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ^� HAZARDOUS SUBSTANCE STORED&C.A.S.# � .A.S.#: CJ III. 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 Ef 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑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 F-11 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR LINING F-]5 GLASS LINING �6 UNLINED ❑95 UNKNOW [:] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑kd�91 TAR ASPHALT F-] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A jq,1 SUCTION A U 2 PRESSURE A U GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION 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 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. d`(u� S 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 lJ 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. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3.W6t�EFILLED WITH SUBST E EMAINING IN INARIAL? YES ❑ NO GALLONS / THIS&RM 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 E JURISDICTION# AGENCY# FACILITY ID# TANKID# I I I J EI I I dbl ? vas 1AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APP OVAL DAA PERMIT EXP ATI N DATE 1 ?hba'i PERMIT AMOUNT SURCHARG AMT. `J FEE CODE RECEIPT# BY: Adik FORM B 6-29-88 THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM`A',UNLESS A RRENT FORMA' HAS BEEN FILED ( ) F DATA PROCESSING COPY