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STATE OF CALIFORNW6 WATER RESOURCES CONTROARD <br /> UND GROUND STORAGE TANK PR RAM <br /> TANK PERMIT APPLICATION INFORMATION d <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> TANK <br /> 1 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> MARK ONLY <br /> ONE ITEM 2 INTERIM PERMIT E] 4 AMENDED PERMIT /A. .. ^�6 TEMPORARY TANK CLOSURE <br /> B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 11; <br /> Ivv - FARM TANK-YES❑ NO ® z <br /> IO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK ID# �- <br /> D. TANK CAPACITY IN GALLONS: (� <br /> C.YEAR INSTALLED <br /> 11. LANK)CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> 3 CHEMICAL PRODUCT 4 OIL <br /> �1 PRODUCT ❑4 GASAHOL E] 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL []99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOA A,B,C.&D <br /> A TYPE OF Er' <br /> LED 3 SINGLE WALLED WITH EJ(TERIORUNFA <br /> El 95 UNKNOWN <br /> ED 4 SECONDARY CONTAINMENT 99 OTHER <br /> SYSTEM LED 0 2 STAINLESS STEEL �3 FIBERGLASS 4 STEELCLADW/RBERGLASS REINFORCED PLASTIC <br /> B.TANK E]6 POLYVINYLCHLORIDE �7 UMINUM 0 100%METHANOL COMPATIBLE FRP <br /> MATERIAL 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> El 1 RUBBERUNED 2ALKYD LINING --13 EPDXY LINING n</PHENOLIC LINING <br /> C. INTERIOR 6 UNLINED 95 UNKNOWN <br /> LINING ❑5 GLANS LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES ❑NO ❑59 OTHER <br /> ❑ I POLYETHLENE WRAP 2TAR OR ASPHALT ❑3VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> D. CORROSION <br /> PROTECTION F-15 CATHODIC PROTECTION E]91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A 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 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 FIBERGLASSPIPE <br /> A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> D. MATERIAL A U S ALUMINUM <br /> A U 9 GALVANIZED STEEL A 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 5 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION 8 91VNONEE WELLS P S 95EU KNOWN LECTRONIC MONITOR F 6 99TGROUND WATER MONITORING WELLS <br /> P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3. WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT M T iLi+' DYES � NO <br /> SUBSTANCE RENTAL N IN GALLONS <br /> THIS FORM HAS BE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> AP ANT'S AME(PRINTED&SIGN URE) d(/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> (fid 2 6a C> U <br /> APPROVED BY NAME — PHONE X WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> CHMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT If BY: <br /> ECK X PERis <br /> FORM B(3-7-BB) THIS FORM MUST SE ACCOMPANIE oT A FACILITY/DITE ATA PPROCESS NOGRMOM'A',UNLESS A ENT FORMA' HAS BEEN FILED <br />