COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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t STATE OF CALIFORNIM WATER RESOURCES CONTRCo ARD tibf sM{ FORM 'B': UNDE GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. °•�,.' P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 15- FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2!42 ` FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I Q A. OWNERS TANK ID# oN L B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q c) Ell II. TANK RONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. 4 A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 4111, ❑3 CHEMICAL PRODUCT ❑ 4 OIL1 PRODUCT F-]4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS �i•� 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 i HAZARDOUS SUBSTANCE STORED&C.A.S.# �A l C.A.S.#: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER F] 1 STEEL/IRON F-]2 STAINLESS STEEL F-] 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-] 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM E:]8 100%METHANOL COMPATIBLE FRP j ❑ 9 BRONZE 10 GALVANIZED STEEL !KNOWN 99 OTHER f F11 RUBBER LINED F-] 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING f C.ILINING IN NG R ❑ 5 GLASS LINING ❑ 6 UNLINED KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3VINYL RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER E IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE f A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER U I B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER 4 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE r C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP F A U 9 GALVANIZED STEEL U 9 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 PP SS 44 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE Sem-� UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH J SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ❑ NO ( w THIS FORM HAh BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. CC APPLICANT'S NAME(PRINTED&SIGNATURE) DATE Cf I LOCAL AGENCY USE ONLY E' COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1 II I I 1 -1 L I I EEo o= L-) LI I O I t I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAMPHONE#WITH AREA CODE / u0 !. PERMIT NUMBER PERMIT APP OVA DATE ER EXPIRAT164 DATE Y CHECK# PERMIT AMOUNT SURCHARGE A�T. FEE CODE JRECEIPT# BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY