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STATE OF CALIFORN16 WATER RESOURCES CONTRWOARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. o <br /> TANK <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE B TANK REMOVED (05;) <br /> W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: /S6 S S• 7 FARM TANK-YES❑ NO GJ <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> rn <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: uk- <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: p <br /> II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL r-] 2 PETROLEUMC. ❑ 1 UNLEADED LEADED 3 DIESEL <br /> 7 3 CHEMICAL PRODUCT F-1 B.4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> E] 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 C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,8 D <br /> A TYPE OF ❑ 1 W LE WALLED F1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SING WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEUIRON F-] 2 STAINLESS STEEL F-1 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-] 5 CONCRETE F�6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOLCOMPATIBLEFRP <br /> MATERIAL <br /> 9 BRONZE F--] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C. INTERIOR r-] 5 GLASS LINING F-1 6 UNLINED �5 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES 0 NO [:] 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP [:] 2 TAR OR ASPHALT 3 VINYLWRAP Ej 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:]5 CATHODIC PROTECTION Ej 91 NONE UNKNOWN 0 99 OTHER <br /> IV. PIPING INFORMATION IRCLE 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 WALLED A U 3 LINED TRENCH A U 91 NONE A U NKN N A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CO A U 7 STEEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U IZ 5 UNKNO 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 VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S UNKNO 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 INERT 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 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> L 4NG S is <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECKM PERMIT AMOUNT RCHARGE AMT. FEE CODEECEIPT# <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A WENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />