COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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INI WATER RESOURCES CNTR h ARD Y FORM ` : UNDE GROUND STORAGE TANK PRO AM TANK PERMIT I F ATI TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. ��" I MARK ONLY 1 NEW PERMIT F�3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDTANK ONE ITEM ❑2 INTERIM PERMIT 1:14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B.,MANUFACTURED BY: tj Iv C.YEAR INSTALLED D. 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 FUEL2 PETROLEUM B. C. NJ 1 UNLEADED F-] 2 LEADED E]3 DIESEL lisl ❑3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL E]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.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A, ,C,a D A.TYPE OF ❑ 1 DOUBLE WALLED ®3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ INGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER Eiz 1 STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ®4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRLTE F-16 POLYVINYL CHLORIDE 7 ALUMINUM ❑8 1 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑99 OTHER C.INTERIOR ® 1 RUBBER LINED ❑2 ALKYD LINING ®3 EPDXY LINING ®4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ® IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES ❑ NO 99 OTHER uiK D.CORROSION ❑ i POLYETHLENE WRAP ❑2 TAR OR ASPHALT ®3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE Fil 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTIONU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGL WALLED. A, U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A:b 1 STEEL%IRON: j a'# dy 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 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. S 1 VISUAL CHECK 65 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER Vl. INFORMATION TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DAT LAST USED(MO/YR) 2. ESTIMATED QUAN ITY OF 3.WAS TANK FIL D WITH Al ft- SUBSTANCE)r/PiG IN GALLONS INERT M . [:]YES NO THIS FORM HAS BEEN COMPLETED UNDER PENAL ERJURY,A THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. A PL ANTS NAME PRINTED&SI TUBE) DATE p i 6Vx LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# IT-] LLI J2 L1-TT4 CURRENT LOCAL AGENCY F CILITY ID# APPROVED BY AME "'fPHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PE4MIT EXPIRAT N DATE CHECK# PERMIT AMOUNT SURC14ARGE AMT.' FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI A FACIlITY/SITE APPLICATION, FOR ''JAW!,UNLESS ENT FORM`A` HAS BEEN FILED DATA PROCESSINGY