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STATE OF CALIFORP" % WATER RESOURCES CONT . BOARD <br /> FORM IBI: UNOtRGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION ` a ` <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 7` <br /> MARK ONLY ❑ I NEW PERMIT 03 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 RMANENTLY CLOSE` o• 10 <br /> ONE ITEM 2 INTERIM PERMIT q AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVE Q y <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 Q / w <br /> d e-/,c. ��� FARM TANK•YES NO I- <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN SO SPECIFY <br /> A. OWNERS TANK ID A B. MANUFACTURED BY' 00 <br /> TV <br /> C. YEAR INSTALLED 6114C D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. [:] 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED ED] 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT / OIL 7 PRODUCT � q GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN �2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.p <br /> CAS R: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D <br /> A TYPE OF ❑ 1 DOUBLE WALLED E:] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED D/SECONDARY CONTAINMENT Ej 99 OTHER <br /> S.TANK 1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS d STEEL CLAD W/FIBERGLASS REINFORCEDPLASTIC <br /> ED <br /> MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> D 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED El 2 ALKYD LINING 3 EPDXY LINING D 4 PHENOLIC LINING <br /> LINING ❑5 GLASS UNING D 6 UNLINED <br /> 95 UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH 10091 METHANOLI YES 0 NO [:D 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP D 2 TAR OR ASPHALT 3 VINYL WRAP ❑a FIBERGLASS REINFORCED 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 U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2'DOUBLE WALLEO A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U q FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 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 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S C ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES D 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 6 SIGNATURE) GATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION R AGENCY B FACILITY ID B TANK ID B <br /> 1 171CURRENT LOCAL AGENCYF CILITY IDP APPROVED BY NAME PHONEY WITH AREA CODE <br /> r <br /> PERMIT NUMBER y PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 9� l <br /> CNECKE PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE RECEIPT q BY: <br /> FORM B(6-29-88) THIS FORM MUST BEACCOMPA,.--o BY A FACILITYISITE APPLICATION, FORM `ALESS A CU <br /> UNRRENT FORMA' NAS BEEN FILED <br /> _____� DATA PROCESSING COPY <br />