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TAT CALIF WATER RESOURCES CONTR D <br />• J:ORM `B°: U D G UND STORAGE TANK P <br />T 'TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br />MARK ONLY ® 1 NEW PERMIT E�l 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY <br />ONE ITEM ❑ 2 INTERIM PERMIT 12 4 AMENDED PERMIT [:] 6 TEMPORARY TANK CLOSURE [:] 8 TANK REMOVE[ <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: STOCKT,ON KAISER MEDICAL CENTER FARM TANK - YES E <br />1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF N - S S ECIFY <br />A. OWNERS TANK ID # B. MANUFACTURED BY: OWENS-CORNING <br />C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 12000 <br />II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. <br />56A ,y�� gyp <br />� w <br />w. <br />-o <br />y®o �P <br />!`I nCIM TAAIV 10 <br />UE <br />A. r_� 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br />B. <br />C. Hi1'UNLEADED � 2 LEADED �3 DIESEL <br />3 CHEMICAL PRODUCT QX 4 OIL <br />®1 PRODUCT <br />4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br />E 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN <br />2 WASTE <br />❑ 7 METHANOL [:] 99 OTHER (DESCRIBE IN ITEM D, BELOW) <br />D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF <br />HAZARDOUS SUBSTANCE STORED & C.A.S. # OIL NO. 2 C.A.S. W <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A, B, C, & D <br />A. tYPE OF <br />®-1 DOUBLE WALLED <br />❑ 3 SINGLE WALLED WITH EXTERIOR LINER <br />95 UNKNOWN <br />SYSTEM <br />E] 2 SINGLE WALLED <br />4 SECONDARY CONTAINMENT <br />99 OTHER <br />3 GRAVITY A U 91 NONE <br />;❑ 1 STEEL/IRON <br />2 STAINLESS STEEL <br />QX 3 FIBERGLASS <br />4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />� 5 CONCRETE <br />F_']6 POLYVINYLCHLORIDE <br />� 7 ALUMINUM <br />� 8100% METHANOL COMPATIBLE FRP <br />MATERIAL <br />9 BRONZE` <br />10 GALVANIZED STEEL <br />[::] 95 UNKNOWN <br />99 OTHER <br />A U <br />1 RUBBER LINED <br />� 2 ALKYD LINING <br />F-]3 EPDXY LINING <br />E]4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />� 5 GLASS LINING <br />F_� 6 UNLINED <br />A U <br />F_� 95 UNKNOWN <br />8 100% METHANOL COMPATIBLE FRP <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />YES ® NO <br />❑ 99 OTHER <br />D. CORROSION <br />❑ 1 POLYETHLENE WRAP <br />❑ 2 TAR OR ASPHALT <br />® 3 VINYL WRAP <br />® 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />❑ 5 CATHODIC PROTECTION <br />❑ 91 NONE <br />❑ 95 UNKNOWN <br />[:] 99 OTHER <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />ANT'S N IN D &SIGNATURE) <br />FACI 3Afi <br />A. SYSTEM TYPE <br />A qD <br />1 SUCTION A <br />U 2 PRESSURE <br />A & <br />3 GRAVITY A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />APPROVE Y NAME <br />. CONSTRUCTION <br />A U <br />1 SINGLE WALLED A <br />U 2 DOUBLE WALLED <br />A U <br />3 LINED TRENCH A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />PERMIT APPROVAL DATE <br />PERM EXPIRATION DATE <br />A U <br />1 STEEL/IRON A <br />U 2 STAINLESS STEEL <br />A U <br />3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE A U 91 NONE <br />C. MATERIAL <br />A U <br />5 ALUMINUM A <br />U 6 CONCRETE <br />A U <br />7 STEEL CLAD W/FRP A U <br />8 100% METHANOL COMPATIBLE FRP <br />A U <br />9 GALVANIZED STEEL A <br />U 95 UNKNOWN <br />A U <br />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 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS (Da) 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br />INFORMATION <br />1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH <br />GALLON$ <br />SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:]NO <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />ANT'S N IN D &SIGNATURE) <br />FACI 3Afi <br />y� <br />DATE �q <br />l_Y_l:I�L <br />LY <br />COUNTY # JURISDICTION # <br />AGENCY # <br />FACI 3Afi <br />TANK ID # <br />kCURi%l� <br />/°� <br />Vol aF-/] <br />OCAL AGENCY FACILITY ID # <br />APPROVE Y NAME <br />PHONE # WITH AREA CODE <br />ERMIT N <br />PERMIT APPROVAL DATE <br />PERM EXPIRATION DATE <br />CHECK # PERMIT AMOUNTSURCHARGE AMT. FEE CODE RECEIPT # BY: <br />FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FA( I/SITE APPLICATION, FORM `A', UNLESS A CURRENT FORMA' HAS BEEN FILED <br />DATA PROCESSING COPY <br />FJ, <br />z <br />'�c <br />