COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN WATER RESOURCES CONTR O r= FII `B': UND GROUND STORAGE TANK PRFR v = TANK TANK PERMIT APPLICATION INFORMATIO COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR CFIF,; 80 MARK ONLY NEW PERMIT F-13 RENEWAL PERMIT E 5 CHANGE OF INFORMATION 7iP D TILUL ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE iTAjqSBWt@ /TT FACILITY/SITE NAME WHERE TANK IS INSTALLED: " 21 s FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY CD Q , A. OWNERS TANK ID# I—jjjjg!n� B. MANUFACTURED BY: �`4 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. 1 UNLEADED LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL F-1 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.#k III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED [:]4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON F-]2 STAINLESS STEEL 3 FIBERGLASS F-]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK �5 CONCRETE t ( 8 POLYVINYLCHLORIDE ❑ 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE 10 GALVANIZED STEEL [:] 95 UNKNOWN 99 OTHER C. INTERIOR 1 RUBBER LINED F-12 ALKYD LINING �3 EPDXY LINING F-14 PHENOLIC LINING LINING s ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN y t p4"' IS LINING MATERIA ISLE WITH 100%METHANOL? Eq'YES [:] NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-] 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC PROTECTION D 5 CATHODIC PROTECTION ❑ 91 NONE El 95 UNKNOWN [j 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 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U "2 DOUBLE WALLED A U3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) ACU_'14 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 U 95 UNKNOWN A U 99 OTHER ��)) LEAK DETECTION SYSTEM CIRCLE P 1700RIMARY,OR S FOR SECOOARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. Y)s P S 1 VISUAL CHECK P fj INVENTORY RECONCILIATION P S 3 VADOSE WELLS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS v S 6 PRECISION TESTING PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK OERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLID WITH SUBSTANCE REMAININ7 I TE [::]YES � NO GALLONS INERT MA 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 COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I I I © o -p- 3 -sEololoM CURRENT AL AGENCY FACILITY ID# APPROVED BY JNA PHONE#WITH AREA CODE k5 /1 27 0k PERMIT NUMB R PERMIT APPROVAL DATE I FIERMIT E PIRATION DATE CHECK# PERMIT AMOUNT JWCHARGE AMT. FEE CODE PT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY