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STATE E aF CALIFOMW WATER RESOURCES CONTO BOARD <br /> FORM `Q' <br /> UN �`' �`~• <br /> GROUND STORAGE TANK PROGRAM <br /> TANKZj' TANK.PERMIT APPLICATION INFORMATION <br /> ;COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION ' <br /> FOR EACH TANK: <br /> MARK;ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 1 PERMANE LY <br /> ONE IM ED 2 INTERIMPERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK RE OVED <br /> FACILITYTE NAME WHERE TANK IS INSTALLED: S 'l <br /> llt- Ir 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C FARM TA YE <br /> A. OWNERS TANK ID q <br /> B. MANUFACTURED BY: QGEr✓s� '� <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> 11. TANK C LATENTSMARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A• 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. <br /> 3 CHEMICAL PRODUCT 4 OIL ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 1 PRODUCT 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL C]99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.q <br /> C.A.S.q: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> SYSTEM E]2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> B.TANK E]1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE 7 ALUMINUM 8 10091 METHANOL COMPATIBLE FRP <br /> 9 BRONZE M 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR I RUBBER LINED 0 2 ALKYD UNING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING Q 6 UNLINED <br /> 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 1 DD%METHANOL? ❑YES E]NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHL.ENEWRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASSREINFORCEDPLASTIC <br /> PROTECTION 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 <br /> 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 LINfTRENCH U 91 NOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STA U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 8 10096 METHANOL COMPATIBLE FRP <br /> A U 99 O <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> FP <br /> 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> 8 6 PRECISION TESTING P S 7 PRESSURE TESTING <br /> P 8 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P $ 99 OTHER <br /> 1. ESTIMATED DATE LAST USED(MOA I) <br /> 2.ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3•WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? [:]YES r—�NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO , <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) WLEDGEIS TRUE AND CORRECT. <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> couNTY q ' <br /> JURISDICTION 11 AGENCY q <br /> ® FACILITY ID 8 TANK ID N <br /> 7 oFT77U <br /> CURRENT LOCAL AGENCY FACILI ID I <br /> APPROVED 8Y NAME PHONE 0 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE LL� <br /> CHECK q PERMIT AMOUNT SURCHARGE AMT. FEE CODE IPT q /r /7 <br /> BY:� <br /> 1 oRM B(s-z9•ee) THIS FORM MUST BE ACCOMPANLEIi n r A FACILITY/SIWE <br /> TE APPLICATION, FOR M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />