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STATE J -%TE OF CALIFORNO WATER RESOURCES CONTR D <br />R <br />FORMV: ERGROUNDSTORAGETANK <br />UND PRO!Ft:M <br />TANK PERMIT APPLICATIINFORMATION <br />TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br />MARK ONLY r --j I NEW PERMIT F-� 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br />ONE ITEM [-] 2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: jkj�2 I <br />-.Aj A FARM TANK -YES D NO <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -_IF UNKNOWN - SO SPECIFY <br />A. OWNERS TANK ID # ,JLJ)JI�5 B. MANUFACTURED BY: <br />C. YEAR INSTALLED I gjjgZg L -WK CAPACITY IN GALLONS: <br />11. TANK CONTENTS <br />I I <br />IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A-11) IS NOT MARKED COMPLETE ITEM D. <br />A. MOTOR VEHICLE FUEL F-1 2 PETROLEUM <br />B. <br />C. Ep"rUNLEADED 0 2 LEADED E] 3 DIESEL <br />r -� 3 CHEMICAL F-] 4 OIL <br />PRODUCT <br />❑ 4 GASAHOL F-� 5 JET FUEL [:] 6 AVIATION GAS <br />[:] 5 HAZARDOUS ❑ 80 EMPTY [:] 95 UNKNOWN <br />E] 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. # C.A.S. #: <br />1� ; xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, 13, C, & D <br />A. TYPE OF <br />F-� I DOUBLE WALLED <br />F-� 3 SINGLE WALLED WITH EXTERIOR LINER <br />❑ 95 UNKNOWN <br />SYSTEM <br />MGLE WALLED <br />4 SECONDARY CONTAINMENT <br />❑ 99 OTHER <br />B. CONSTRUCTION <br />EUIRON <br />2 STAINLESS STEEL <br />F-� 3 FIBERGLASS <br />F-] 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL <br />F-1 5 CONCRETE <br />❑ 6 POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />[-] 8 100% METHANOL COMPATIBLE FRP <br />[:] 9 BRONZE <br />10 GALVANIZED STEEL <br />95 UNKNOWN <br />E] 99 OTHER <br />[::] I RUBBER LINED <br />2 ALKYD LINING <br />F-� 3 EPDXY LINING <br />[:] 4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />F-1 5 GLASS LINING <br />Eg-,&mINED <br />C. MATERIAL, <br />F-1 95 UNKNOWN <br />5 ALUMINUM <br />❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />[::]YES ONO <br />Ej 99 OTHER <br />D. CORROSION <br />PROTECTION <br />F-1 I POLYETHLENE WRAP <br />❑ 2 TAR OR ASPHALT <br />F-1 3 VINYL WRAP <br />F-1 4 FIBERGLASS REINFORCED PLASTIC <br />U 95 UNKNOWN <br />E] 5 CATHODIC PROTECTION <br />NONE <br />95 UNKNOWN <br />99 OTHER <br />IIV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TM <br />A U <br />1 SUCTION <br />AtV2 <br />PRESSURE <br />A U <br />3 GRAVITY A U <br />99 OTHER <br />B. CONSTRUCTION <br />�� <br />SINGLE WALLED <br />A <br />U 2 DOUBLE WALLED <br />A U <br />3 LINED TRENCH A U <br />95 UNKNOWN A U 99 OTHER <br />• el <br />STEEL/IRON <br />A <br />U 2 STAINLESS STEEL <br />A U <br />3 POLYVINYL CHLORIDE (PVC) <br />A U 4 FIBERGLASS PIPE <br />C. MATERIAL, <br />A U <br />5 ALUMINUM <br />A <br />U 6 CONCRETE <br />A U <br />7 STEEL CLAD W/FRP <br />A U 8 100% METHANOL COMPATIBLE FRP <br />• 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 13E CIRCLED. <br />HECK & S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />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 />I1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH NO <br />I SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES =[ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />[!!!'S NAME (PRINTED & SIGNATURE) DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY# JURISDICTION # AGENCY# FACILITY ID # TANK ID# <br />UITJ o -I I I -, I o I u 10 <br />CURRENT LOCAL AGENCY FACILITY ID # ;A P76VED BY NAME PHONE # WITH AREA CODE <br />dl�e� <br />U R <br />[PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIR#ION DATE <br />C C <br />CHIECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE 4RECIEIPT # BY: <br />FORM B (3-7-88) THIS FORM MUST BE ACCOMPANI A FAcury/siTE APPLICATION, FORM W, UNLESS FORM `A' HAS BEEN FILED <br />I DATA PROCESSING COPY <br />