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STATE OF CALIFORWATER RESOURCES CONT ARD <br /> FORM W: UND GROUND STORAGE TANK - I RAM �m <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Zo <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT u 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE <br /> /` w <br /> a GG 77y ARM TANK-YES❑ NO (JO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: (/V � ,jh <br /> O7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cn <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK ID# n <br /> D. TANK CAPACITY IN GALLONS //ry <br /> C. YEAR INSTALLED <br /> II. TANK LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL E] 2 PETROLEUM <br /> B C. ❑ 1 UNLEADED 2 LEADED D 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL <br /> 1 PRODUCT ❑ 4 GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL D 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑�OUBLE WALLED � 3SINGLE WALLED WITH EXTERIOR LINER �95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON ❑ 2 STAINLESS ST EEL F-1 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE F�7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 0 95 UNKNOWN DI 99 OTHER <br /> 1 RUBBER LINED El ALKYD LINING 0 3 EPDXY LINING DHENOLIC LINING <br /> C. INTERIOR 0 5 GLASS LINING El 6 UNLINED UNKNOWN ,J <br /> LININGF� <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES � NO 990THER <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT F-13 LWRAP D 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-15 CATHODIC PROTECTION [:] 91 NONE 95 UNKNOWN Ej 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 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE 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 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL Ao 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 /> r(✓ P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> ,N111i- 6 PRECISION TE STING 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 3 WAS TANK FILLED WITH <br /> L ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? DYES [:] NO <br /> SUBSTANCE REMAINING IN 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 k AGENCY# 22 0 <br /> PHONE N WITH AREA CODE <br /> CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME <br /> Gov ?m/` f <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> BY: <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />