COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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Irw 74 STATE OF CALIFORNI WATER RESOURCES CONTROWARD q q�',Y YS,ref vJ FORM B': UNDE GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION 1 FORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. MARK ONLY " NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED /j57 r-la FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ O .0� 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N A. OWNERS TANK ID# B. MANUFACTURED BY: U/U C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 4-4an II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Y A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT 4 GASAHOL ❑ 5 JET FUEL ❑ 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.#: 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 In 99 OTHER 1 STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS F—] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK --- CONCRETE F—]6 POLYVINYLCHLORIDE F—] 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL F l 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING ❑3 EPDXY LINING E] 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 12K99 OTHER LAK D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION U 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 A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER " A `V' 1 STEEL/IRON ' a A. U ?'STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUMj'A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. No 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 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) 3.WAS TANK FILLED WITH q� SUBSTANCE REMAI GALLONS INERT MATERIAL? ❑YES QC NO THIS FORM BEEN COMPLETED UNDER PENAL PER RY, 0 THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLI N SNAME(PRI TED SIG TUBE) DATE 'A , t1 '� LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I- I I I El I I L-1 I / ® f LL I 1,-�l CURRENT LOCAL AGENCYITY ID# APPROVED BY NAME PHONE#WITH AREA CODE � I 2�ff PERMIT NUMBER PERMIT APPROVAL DATE PWAIT EXPIRATIOk6ATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT FORM B(6-29-88) THIS FORM MUST BE ACCOMPANI (A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A' RENT FORM-A' HAS BEEN FILED DATA PROCESSING COPY