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STATE OF CALIFORNi�, WATER RESOURCES CONTR< OARD <br /> UND GROUND STORAGE TANK PR0 ROAM <br /> FORMW:. , <br /> TANK TANK PERMIT APPLICATION INFORM <br /> C/COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> CHANGE OF INFORMATION 7 PERMANENTLY C <br /> 1 NEW PERMIT 1 3 RENEWAL PERMIT 0 8 TANK REMOVED t <br /> MARK ONLY 0 4 AMENDED PERMIT �6 TEMPORARY TANK CLOSURE <br /> ONE ITEM 2 INTERIM PER 6P rj,71 ARM TANK-{YES❑ NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: L <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBM <br /> SPECIFY <br /> BY: <br /> A. OWNERS TANK ID# �Q V <br /> L D. TANK CAPACITY IN GALLONS: <br /> G YEAR INSTALLED <br /> 11. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A 1),IS NOT MCpKE ❑D COMPLETE ITEM D.LEADED Ej 3 DIESEL <br /> A. 1 MOTOR VEHICLE FUEL 0 2 PETROLEUM B CT 0 4 GASAHOL D 5 JET FUEL 0 6 AVIATION GAS <br /> 0 3 CHEMICAL PRODUCT F-11 PRODU <br /> 4 OIL 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 0 5 HAZARDOUS 0 80 EMPTY []95 UNKNOWN ❑2 WASTE <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.W <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A TYPE OF ❑i0 LE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER F795 UNKNOWN <br /> SYSTEM 2 NGIE WALLS 4 SECONDARY CONTAINMENT �99 OTHER <br /> IV 1 STEBUIRON 2 STAINLESS STEEL F-] 3 FIBERGLASS 4STEEL CLAD W/RBERGUISS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 810096 METHANOL COMPA11BLEFRP <br /> MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> ❑ 1 RUBBER UNE 2 NKYDUNING 3 EPDXY LINING I�44'PHENOUC LINING <br /> C UN INTERIOR <br /> ❑ 5 GLASS LINING 6 UNLINED [J" 95 N <br /> ISLINING MATERIAL COMPATIBLE WITH 100%MEHANOL? YES [--1 NO 99OTHER <br /> D. CORROSION ❑ 1 POLYEFHLENE WRAP 2TAR OR ASPHALT 3 WRAP 4 FIBERGLASS REINFORCE PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 0 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSITTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U S 10D%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P 8 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> 39 v 3 000 <br /> CURRENT LOCAL AGENCY FACILITY 10 N APPROVED BY NAME PHONE N WITH AREA CODE <br /> LC.i 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CMECKN PERMR AMOUNT SURCXA110E AMT. FEE CODE RECEIPT BY:Im <br /> FORM B(6-29-68) THIS FORM MUST BE ACCOMPANI A FACILITY/MTE APPLICATION, FORM 'A!,UNLESS A CURRENT FORM W HAS BEEN FILED <br /> DATA PROCESSING COPY <br />