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STATE OF CALIFORN� WATER RESOURCES CONT BOARD «`.:°'., . <br /> FORM W: UN GROUND STORAGE TANK PRMRAM <br /> TANK PERMIT APPLICATION INFORMATION �,,�, <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I T31 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO -� <br /> 1 L? <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERSTANKID# B. MANUFACTURED BY: Ze < <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> W <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(aCOMPLETE ITEM D. <br /> ISNOT MARKED,. N <br /> A. ❑v 1 MOTOR VEHICLE FUEL F_� 2 PETROLEUM B. G 1 UNLEADED 0 2 LEADED 3 DIESEL N <br /> ❑ 3 CHEMICAL PRODUCT [-] 4 OIL 1 PRODUCT 4 GASAHOL E] 5 JET FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS F-] 80 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 C.A.S.#. <br /> HAZARDOUS SUBSTANCE STORED 8,C.A.S.# <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D <br /> A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE WALLED F-1 4 SECONDARY CONTAINMENT E] 99 OTHER <br /> It STEDUIRON F-1 2 STAINLESS STEEL El 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F� 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL Fl 9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN [:] 99 OTHER <br /> 1 RUBBERLINED F-1 2 ALKYD LINING 3 EPDXY LINING E]4 PHENOLIC LINING <br /> C. INTERIOR <br /> LINING F-15 GLASS LINING LLf 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 YES E] NO 99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-] 5 CATHODIC PROTECTION [:]91 NONE 95 UNKNOWN 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&95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLOHIDE(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 COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A O 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 OP S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR PS 5 GROUND W TER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN INERT MATERIAL' El YES E] NO <br /> JVA GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FACILITY ID# TANK ID# <br /> COUNTY# JURISDICTION# I ATIGENCY'# = O O O <br /> CURRENT LOCAL AGENCY FACILITY ID p <br /> APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NU BEP PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT M <br /> BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE A FACILITY pIT AAP PROCESS PROCESSING 'K,UNLESS A W JRENT FORMA' HAS BEEN FILED <br />