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STATE 01"FCALIFORINI WATER RESOURCES COT OAD <br /> F ` ' G ROUND STORAGE TANK I INRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 <br /> MARK ONLY 1 NEW PERMIT ®3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT [:]4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z- ba FARM TANK YES❑ NO <br /> 1. 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: /O <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPI ETE,ITEM C IF'(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ®2 LEADED 3 DIESEL <br /> 3 CHEMICALPRODUCT ®4 OIL DUCT ❑4 GASAHOIF 5 JET FUEL 6 AVIATION GAS <br /> ®5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN 2 STE "` ®7 METHANOL r 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 /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A,B,C,.&D <br /> A.TYPE OF ❑1 DOUBLE WALLED ®3 SINGLE WALLED WITH EXTERIOR UN ER ❑95 UNKNOWN <br /> SYSTEM Q'TSINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEL/IRON ❑2 STAINLESSSTEEL 3 FI RGLASS ❑4 STEEL CLAD W/FIBERGLASS'REINFORCED PLASTIC <br /> B.TANK L 5 CONCRETE ❑6 POLYVINYL CHLORIDE �7 ALUMINUM �8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> ®9 BRONZE ® 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER <br /> ® 1 RUBBER LINED ®2 ALKYD LINING ®3 EPDXY LINING F—]4 PHENOLIC LINING <br /> C.LINING R �5 GLASS LINING fi Efl F—]95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METI+ANOL?. E]YES ❑NO [:]99 OTHER <br /> D.CORROSION ❑1 POLYETHLENEWRAP ®2 TAR gWPHALT &aVJdOYLWRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A& <br /> 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 01 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 GALVANIZES 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 8 1 VISUAL CHECK <08 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P&6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGECY'USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> ]I--- - I-- lZ <br /> C./ <br /> CURRENT LOCAL AGENCY FACILITY 10 APPROVE BY NAME PHONE#f WITH AREA CODE <br /> PERMIT NUMBER PERMIT APFIROr DA PERmijAxPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AdT. ` FEE CODE RECEIPT# BY: <br /> z <br /> FORM B'(6-29-Be) THIS FORM MUST BEAC PANT A FACILITY/ CATION, FORM` ',UNLESS A ENT FORMA' HAS BEEN FILED <br /> zDATA PROCESSINGY <br />