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STATE 1 WATER RESOURCES CONTO BOARD sf�..�: •�. <br /> FORMV:: UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION - <br /> COMPL A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E]7 PERMANENTLY CL T NK 10 <br /> ONE ITEM 21NTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ®8 TANK REMOV <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> FARM TANK-YES <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),Is NOT MARKED,COMPLETE ITEM D. <br /> A. ® i MOTOR VEHICLE FUEL F-�2 PETROLEUMB. C. ® 1 UNLEADED 2 LEADED E]3 DIESEL <br /> 3 CHEMICAL PRODUCT ®4 OIL Ell PRODUCT �4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS E380 EMPTY [—]95 UNKNOWN 2 WASTE El 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> 111 TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER F-�95 UNKNOWN <br /> SYSTEM E]2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON r STAINLESS STEEL M 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. <br /> MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F--j 7 ALUMINUM LI 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE ❑10 GALVANIZED STEEL E]95 UNKNOWN E3 99 OTHER <br /> C.INTERIOR ❑ 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS UNING 6 UNLINED <br /> 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES E]NO E]99 OTHER <br /> D.CORROSION ❑ i POLYETHLENE WRAP 7 2 TAR OR ASPHALT ❑3 VINYL WRAP r-�4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION E]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 A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 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 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 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 /> Lpp <br /> S1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> S 6 PRECISION TESTING 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 <br /> 1. ESTIMATED DATE LAST USED(MO/ R) 2. ESTIMATED QUANTITY OF <br /> 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING W GALLONS INERT MATERIAL? ®YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# <br /> TANK ID# <br /> DE — L [-�j 47-" 12— <br /> LIT� <br /> CURRENT LOCAL AGENCY F ILITY ID 8 APPROVED BY NA E <br /> LZI PHONE k WITH AREA CODE <br /> PEREft <br /> R PERMIT APPROVAL DATE RMI APIRAT A E <br /> CHEPERMIT AMOUNT RCHARGE AMT. FEE CODE <br /> IPT N BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W NAA RcaM cu cn <br />