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yt'L�uOe.�hE. <br /> STATE OF CALIFORNI WATER RESOURCES C©NTROop a <br /> FORM 'g'; UNDE ROUND STORAGE TANK PROGRAM v. o <br /> TANKLTANK PERMIT APPLICATION INFORMATION u <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT E] 6 TEMPORARY TANK CLOSURE 0 6 TANK REMOVED II <br /> C FARM TANK-YES❑ NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY N <br /> A q UY <br /> EYEAR <br /> S TANK 10# # B. MANUFACTURED BY: !"l <br /> D TANK CAPACITY IN GALLONS: <br /> NSTALLED <br /> ll. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> �rl <br /> G. ti UNLEADED 2 LEADE 3 DIESEL <br /> A. 1 MOTOR VEHICLE FUEL � 2 PETROLEUM 0 4 UNLEADED <br /> GASAHL E] 5 LEA FUEL ION GAS <br /> E] 3 CHEMICALPRODUCT L_S 4 OIL PRODUCT <br /> 5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN 2 WASTE <br /> El 7 METHANOL Q 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 0, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C A,S <br /> HAZARDOUS SUBSTAN STORED&G A.S.# <br /> Ill. TANK CONSTR CTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 KNOWN <br /> A.TYPE OF (� OTHER <br /> SYSTEM IJ 2 SINGLEWALLED �4 SECONDARY CONTAINMENT <br /> 1 STEEL/IRON F-1 2 STAINLESS STEEL F_� 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS RFINFORCED PLASTIC <br /> B.TANK FF] 5 CONCRETE F-1 6 POLYVINYLCHLORIDE 0 7 ALUMINUM S 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑ 9 BRONZE El 10 GALVANIZED STEEL ❑95 UNKNOWN E]99 OTHER <br /> 1 RUBBER LINED [:] 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR 5 GLASS LINING F-16 UNLINED 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO p 99 OTHER <br /> D. CORROSION 1 POLYETHLENEWRAP 2 TAR OR ASPHALT 3VINYL WRAP IBERGLASSREINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN E 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 U95 UNKNOWN AU 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A V 91 NON£ A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELAHON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A P FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P 9 99GOR7HUEND WATER MONITORING WELLS <br /> / P S 6 PRECISION TESTING P S 7 PRESSURE TESTING p S 91 NONE p 3 95 UNKNOWN <br /> VI. INFORMATION ON TANK P MANENTLY CLOSED IN PLACE <br /> F�3. WAS TANKFIu£owlrH <br /> 1. ESTIMAST US [t� / ) 2. ESTIMATED QUANTITY OFINERT MATERIAL? YES NO <br /> /J SUBSTANCE REMAINING IN GALLONS <br /> THIS FORM HAS BEEN+ OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> DATE <br /> APP"CANT'S NAM (PRINTED,SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> URISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> TU) � �i cl�j <br /> [EE= <br /> PHONE N WITH AREA CODE <br /> ACILITY ID q APPROVED BY H ME <br /> PERMIT APPROVAL DATE ERMI EXPIRATIO DATE <br /> FEE CODE RECEIPT N BY= <br /> MIT AMOUNT SURCHARGE AMT. �e <br /> L FORM B(6-29-s8) THIS FORM MUST BE ACCOMPANIE Y A FACILITYISITE APPLICATION, FORM 'A',UNLESS A 1ARENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />