COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

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" h STATE OF CALIFORNI WATER RESOURCES CONTR av �.yo7 Thf.sw FORM `B': UND GROUND STORAGE TANK PR o TANK TANK PERMIT APPLICATION INFORM N CO PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATI F OI'J AI $A Ar MARK ONLY NEW PERMIT ❑3 RENEWAL PERMIT R!r5CHANGE OF INFORMATION 7 PERMANENTLY CLO n , fin'. rI l-,p�1�-TL{ ONE ITEM T2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARYTANKCE �I 0I` ',' �AN�`IrMdVED i l ..11. FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ,C q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID - B. MANUFACTURED BY: 00 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ergo II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO PLETE ITEM D. A. U311MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-]3 CHEMICAL PRODUCT F-14 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR F—] 1 RUBBER LINED El2 ALKYD LINING 3 EPDXY LINING F-14 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIALCOPTIBLE WITH 100%METHANOL? ES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP Pal 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 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 02 DOUBLE WALLED A U 3 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) A(S>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 U 95 UNKNOWN A U 99 OTHER �[. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK 2 INVENTORY RECONCILIATION,.p S 3 VADOSE WELLS p 14 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING 7 PRESSURE TESTING P S 91 NONE 95 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.WAST NK FILLED WITH SUBSTANCE R AINING IN GALLONS I E TERIAL? ❑YES ❑ NO TH)§FORM HAS BEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APP ICA T'S NAME(PRINTED& GNATURE) DATE //-17, LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# - [5 AL[all I lJEIl I Le Lo 1)- 13 1 -5 CURRENT L LAGENCY FACILITY APP)jVyBY NA l Z� PHONE#WITH AREA CODE PERMIT NUMBER \`)` J PERMIT APPROVAL DATE PERMIT EXPIRATION GATE 1 CHECK# PERMIT AMOUNT RCHARGE AMT. FEE CODE PT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNLESS A CURRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY