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S CONTROL BOARD <br /> STATE 6Ff"C- ALlF0RNlA ,.'. WATER RESOURCE ' <br /> UNDERGROUND STORAGE TANK PROGRAM ` +wo ! <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK „,.aw.... <br /> ` '.COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN RMATION FOR EACH TANK. I <br /> 10 , <br /> < "MARK"ONLY ❑? NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INF4RMATIQN 7 PERMANENTLY CLOSED <br /> } ;• ONE ITEM :': ❑ 2 INTERIM.PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 6 TANK REMOVED <br /> 7J FACILITY/SITE NAME WHERE TANK IS-INSTALLED: FARM TANK-YES❑ NO ' <br /> TANK DESCRIPTION [ COMPLETE ALL ITEMS=IF UNKNOWN—So SPECIFY <br /> A. OWN TANK ID q rB. MANUFACTURED BY: {/ <br /> C. YEAR,INSTALLED r D. TANK CAPACITY IN GALLONS: <br /> IL TANK C TENTS ': IF(OLII),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO LETE ITEM D. <br /> A. 1.MOTOR VEHICLE FUEL,• [:J_2 PETROLEUM C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT L] H.4 OIL PRODUCT 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS _ <br /> 5 HAZARDOUS 60 EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL. 99 OTHER{DESCRIBE IN ITEM D,BELOW) <br /> 0. IF NOT MOTOR VEHICLE FU T E <br /> HAZARDOUS SUBSTANCE Rl C.A. . C.A.S.q: <br /> Ilia TANK CONSTRUCTI ITEM O IIu eox A,B, ,416 D <br /> A TYPE OF ❑ 1 DOUBLE WALLED` 3 SINGLE WALLED WITH EXTERIOR LINERUNKNOWN <br /> SYSTEM -.': ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEUIRON 2 STAINLESS STEEL . " ❑3 FIBERGLASS-. 4"STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK' ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE E]7 ALU M 8 101A METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYDUNING F-13 EPDXY LINING 4 PHENOUCUNING" " <br /> C.INTERIOR <br /> LIMING E] 5 GLASS UNNG 6•UNUNEDUNKNOWN <br /> ❑IS LINING MATERiALCOMPATIBLE WITH 100%METHANOL? ❑YES NO 99 OTHER <br /> D.CORROSION ❑ I.POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VI WRAP 4 FIBERGLASS REINFORCEOPLASTIC * <br /> PROTECTION. ❑5 CATHODIC PROTECTION 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 n SUCTION A U 2 PRESSURE A U 3 GRAVITY A U- 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> r <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 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 MATERIAE = A U 5 ALUMINUM A U.f�CONCRETE A U 7 STEEL CLAD W/FRP A U B 1009b METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER <br /> LEAK.DETECTION/SYSTEM: CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED) <br /> A "8 1 VISUAL CHECK, _(r S 2 INVENTORY RECONCILIATION' P 6 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> JL' P PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> 1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(M /YR} - 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN , ' INERT MATERIAL? <br /> GALLONS <br /> Lj YES ND <br /> l/ <br /> THIS FORM HAS BEEN CO PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> • ._ s•,� - APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> : COUNTY X JURISDICTION k AGENCY k FACILITY ID k TANK ID X <br /> 77 <br /> CURRENT LOCAL AOENCY FACILITY ID i1 APPROVED BY NAM PHONE it WITH AREA CODE ". <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRA7'1 ATE ' <br /> CHECK/ _ PERMIT AMOUNT SURCHARGE AMT. FEE CODE _':EIPT R_ BY: _ <br /> (6-29,88)„THIS FORM MUST BE ACCOMPANIEDv A FACILIT!</STTE APPLICATION, FORM;`A',UNLESS AY�RENT. FORMA' HAS BEEN FILED <br />