Laserfiche WebLink
STATE OF CALIFORN14h WATER RESOURCES CONTROARDsp <br /> 5 [u.�ey P <br /> FORM `E3': UNDEW5ROUND STORAGE TANK PRO AM .. � <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING 119-FSAMATION FOR EACH TANK. <br /> MARK ONLY © EW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM NTERIM PERMIT q AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE <br /> B TANK REMOVED, <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: GJ FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-30 SPECIFY <br /> Pa <br /> A. OWNERS TANK ID# nt,:�B- RED BY:G. YEAR INSTALLEQ ITY IN GALLONS: <br /> II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> d' <br /> A. [Efi MOTOR VEHICLE FUEL F-] 2 PETROLEUM B C. 1 UNLEADEDLEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OILPRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN ❑ 2 WASTE Q 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.# C.A.S.#: <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 MERIDA LINER UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 0 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEELPRON 0 2 STAINLESS STEEL �3 FIBERGLASS � 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALU <br /> MATERIAL 1:1 �8 10096 METHANOL COMPATIBLE FRP <br /> 9 BRONZE E] 10 GALVANIZED STEEL UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC UNING <br /> LINING ❑5 GLASS LINING 6 UNLINED UNKNOWN <br /> IS LINING MATERIAL COMPAT18LE WITH 100%METHANOL? YES D NO El 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 0 2 TAR OR ASPHALT 3 VINYL W El 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION E] 91 NONE NKNOWN l J 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 V 2 PRESSURE A U 3 GRAVITY A U 99 OTHER V <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 7FRP <br /> A U 1 STEELARON 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 8 100%METHANOL COM <br /> A U 9 GALVANIZED STEEL A 05 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 I 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 /> P S PRECISION TESTIN 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(M <br /> O/YR) 2 ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> J SUBSTANCE REMAINING IN INERT MATERIALS OYES NO <br /> Imo'' GALLONS <br /> THIS FOPM,HAS BEEN COMPLETED UNDER PENALTY OF PERJUPY,AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE"AND CORRECT <br /> APPLICANT'S NAME(PRINTED$SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> sle7l I I LJ L.1 I __1 Fio-F/ /' © Q 111 <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DYE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> dmL <br /> FORM a(3-7-Ba) THIS FORM MUST BE ACCOMPANIE ov A FACILITYISITE APPLICATION, FORM `A',UNLESS AIWRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />