COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

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� ��:..k„ ;t-a-•�^sn;�;•�f .an.' �� .'�';s„ `�'✓'� :• 4?!rs;"'-'^n:^r`'z."'�. , .. ya cF''1`�".� '?3 �''`;'�: p .. STATE OF CALIFORNI WATER RESOURCES CONTRARD W: FORM W: UNDEIMROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED (<--- FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO s I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY t 0 5 4 A. OWNERS TANK ID# UN MANUFACTURED BY: LVj C. YEAR INSTALLED U NL I D. TANK CAPACITY IN GALLONS: OOD 11. TANK 20TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. OTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL 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.# A 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-11 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL 5 CONCRETE E]6 POLYVINYLCHLORIDE F-]7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL NKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED F-12 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOL'LINING LINING ❑5 GLASS LINING ❑6 UNLINED NKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYEFHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL W ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE NKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH k UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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 05 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 P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE IE S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH GALLONS T SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [::] NO THIS FORM 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 ICOUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# cli acs I I I -s-- I o II � Go CURREN'T�LO/1CAAL AG�ENCCYY FACILITY ID# APPROVED BY�AryME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APP VAL DA RMIT EXPIRA N DATE CHECK# PERMIT AMOUNT SURCHAR A . FEE CODE RECEIPT# BY: Idiffik li -- 7 1 FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY