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T,.tu <br /> F CALIFORNIA WATER RESOURCES CONTROL BOARDTUNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION a <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> TANK <br /> MARK ONLY ❑ i NEW PERMIT �3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM Ej 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 198 TANK REMOVED <br /> FARM TANK-YES❑ NO 12:9 Z <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: I <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> B. MANUFACTURED BY: N <br /> C.YEAR INSTALLED 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 /> IV <br /> j <br /> C. ❑1 UNLEADED 2 LEADED E]3 DIESEL 1..) <br /> A. 1 MOTOR VEHICLE FUEL � 2 PETROLEUM <br /> 3 CHEMICAL PRODUCT � 4 OIL <br /> PRODUCT ❑4 GASAHOL �5 JET FUEL �6 AVIATION GAS <br /> 5 HAZARDOUS 0 80 EMPTY E] 95 UNKNOWN WASTE 0 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D <br /> ETANKF-I <br /> OUBLE WALLED ❑3 SINGLE WALLEDWITH EXTERIOR UNER 95 UNKNOWN <br /> NGLE WALLED E]4 SECONDARYOONTAINMENT 99 OTHER <br /> TEELIIRON 2 STAINLESS STEEL �3 FIBERGLASS 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC <br /> ONCRETE 6 PDLYVINYL CHLORIDE �7 ALUMINUM E] B 10096 METHANOL COMPATIBLE FRP <br /> RONZE 10 GALVANIZED STEEL �95 UNKNOWN 99 OTHER <br /> I RUBBER UNED 2 AUKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR [:] 5 GLASS UNING E]6 UNUNED 095 UNKNOWN <br /> LINING <br /> F-1ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHIENE WRAP ❑2 TAA OR ASPHALT ❑3 VINYLWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE of95 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 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> AOU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <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 $ 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> p ®6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH <br /> 1.ESTIMATED LAST (MO/YR) 2. ESTIMATED DUAN REMAINING <br /> I INERT MATERIAL? YES �NO <br /> (V/ S SUBSTANCE REMAINING IN � GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOTHEBEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> ATE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID N TANK ID# <br /> 00 5 o 0 0 <br /> APPROVED BY NAME PHONE 0 WITH AREA CODE <br /> C RENT LOCAL AGENCY FACILITY ID X 7-Z9 8 <br /> PERMITAPPROVAL DATE PERMIT PIRATION DATE <br /> PERMIT NUMBER <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT# BY: <br /> C F M B(3-7-BB) THIS FORM MUST BE ACCOMPANIED Y A FACILITY/DIATA PROCESSING COPY' UNLESS A W RENT FORMA' HAS BEEN FILED <br />