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STATE OF CALIFORN10 WATER RESOURCES CONTRO ARD <br /> FORM ' ': UNDERGROUND STORAGE TANK PRO AM a <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ZCHANGE OF INFORMATION so <br /> ONE ITEM I , 0 7 PERMANENTLY CLOSED TANK <br /> IJ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED ,/ f <br /> FACILITY/SITE NAIVE WHERE TANK IS INSTALLED. + 1 v 1 � <br /> -11FARM TANK-YES 0 NO <br /> L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W <br /> A. OWNERS TANK ID H EI. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: o <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 <br /> 0 1 UNLEADED 0 2 LEADED 3 DIESEL <br /> Q 3 CHEMICAL PRODUCT 4 OIL �1 PRODUCT Q 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY E]95 UNKNOWN [2 WASTE E] 7 METHANOL i� 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# ''J CL <br /> ' � 1� lS # <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A. TYPE OF 1 DOUBLE WALLED El 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 0 2 SINGLEWALLED Ej 4 SECONDARY CONTAINMENT 99 OTHER <br /> B.TANK <br /> © 1 STEEL/IRON 2 STAINLESS STEEL 03 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 0 g CONCRETE <br /> MATERIAL 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 0 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE ❑ 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> Q IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES 0 NO �99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP [:]2 TAR OR ASPHALT 3 VINYL WRAP [-]4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION �CATHODIC PROTECTION E] 91 NONE E:] 95 UNKNOWN <br /> 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF A89YE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A 1 SUCTION A U 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 W2 DOUBLE WALLED 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(PUC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 5 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 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN <br />`-T P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1_ ESTIMA D DATE LAST USED{MO/YR} <br /> =*5R <br /> ITY OF3, WAS TA FILLED WITHNING IN IN RiAL? 0 YES � NO <br /> GALLONSTH' FORMNASBEEN COMPLETED CINDER PENARJUY,AND TO THE BEST OF MY KNOWL GE,IS TRUE AND CORRECT, <br /> APPLICANT'S NAME(PRINTED$SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# <br /> �j /ANK ID# - <br /> CURRE T LOCAL AGENCY FACILITY I k APPRO 8Y 11St <br /> /�] ,/! +� PHONE k WITH AREA CODE <br /> PERMIT NUMBER [•� P€RMIT APPR AL T PE MITE PIRATION DATE <br /> CHECK k PERMIT AMOUNT URCHARGE AMT. FEE CODE <br /> CEIPT k BY: <br /> roRM B(6-29-6s) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />