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STATE OF CALIFORNI& WATER RESOURCES CONTR - OARD <br /> FORM `R': UNQE GROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. oa P <br /> MARK ONLY Cl 1 NEW PERMIT 3 RENEWAL PERMITS CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM F-] 2 INTERIM PERMIT 4 AMENDED PERMIT K6TEMPORARY TANK CLOSURE ❑B TANK REMOVED {( <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0� FARM TANK-YES❑ NO FPr <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID ft21 1 B. MANUFACTURED BY: <br /> C. YEAR INSTALLED tel 0 1 D. TANK CAPACITY IN GALLONS: 10000 <br /> w <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. tR3'1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [:] 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.N C.A.S.N: <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> I STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK Fj 5 CONCRETE 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> © 9 BRONZE 10 GALVANIZEDSTEEL [::] 95 UNKNOWN %OTHER <br /> C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING F—] 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING 5 GLASS LINING ❑ 6 UNLINED 995 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? YES ❑ NO I J 99 OTHER <br /> D. CORROSION 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP [:] 4 FI8ERGLASSREINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE rZ95 UNKNOWN E:] 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 /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS RPE <br /> C. MATERIAL A U 5 ALUMINUM A#N6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 DO%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 /> S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> bp <br /> S 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 <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS 6NERT MATERIAL? E] 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> E <br /> JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> [M I I I I E o b o c� W <br /> AGENCY FACILITY BI# APPROYED BY NAMEPHONE S MY ITH AREA CODE <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(3a-68) THIS FARM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM `A',UNLESS k CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />