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STATE QF CALIFORN WATER RESOURCES CONTR ARD g° �a;'�F <br /> S I <br /> ' ROU ST A t <br /> TANK TANK PERMIT AP LICAT INFORMATION <br /> COMP ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o!! <br /> I <br /> MARK ONLY 2111NEW PERMIT F-1 3 RENEWAL PERMIT ®5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®B TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: v 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: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM CMF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. EEr'l MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ® 1 UNLEADED LEADED El 3 DIESEL <br /> 3 CHEMICAL PRODUCT ®4 OIL ;PRODUCT ®4 GASAHOL 5 JET FUEL ®6 AVIATION GAS <br /> 5 HAZARDOUS ® 80 EMPTY ®95 UNKNOWN 2 WASTE ❑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.# C.A.S.#: " <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF E i DOUBLE WALLED F­j 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM EaKNGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEL/IRON ®2 STAINLESS STEEL F-�3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE E]6 POLYVINYL CHLORIDE ®7 ALUMINUM F-18 10016 METHANOL COMPATIBLE FRP <br /> 'MATERIAL <br /> 9 BRONZE ® 10 GALVANIZED STEEL ®95 UNKNOWN ®99 OTHER <br /> C.iN7ER10R 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ®4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING LINED E]95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES` E NO ❑99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-1 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ®5 CATHODIC PROTECTION ONE El95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U 1F UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A Z 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A dV 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 STEEL/IRON A U 2 STAINLESSSTEEL 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 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL 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 13E CIRCLED. <br /> P 8 1 VISUAL CHECK 03 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS' <br /> P 8 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/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]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 AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> E[ LIL 1110 <br /> CURRENT LOCAL AGENCY FACILITY 10# APP VED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT PPR VAL D PERMIT EXPIRATIgh DATE <br /> '.`. CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# B@ <br /> A' <br /> FORM B(6-29-86) THIS FORM MUST BE ACCOMPAMIlM A FACII Y/SITE APPLICATION, FOR `A',IINLESS AlftENT FORM`A' HAS BEEN FILED <br /> D�ATA PROCESSINGY <br />