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TOFICALIFORN OARD <br />WATER RESOURCES CONTR <br />`P <br />k' `% GROUT TA P A _ o <br />TANK TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br />MARK ONLY galoNEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 PERMANENTLY CL K <br />ONE ITEM ❑ 2 INTERIM PERMIT ® 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: 2 FARM TANK - YES ® NO <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY <br />A. OWNERS TANK ID # B. MANUFACTURED BY: <br />C. YEAR INSTALLEDednCIS2 D. TANK CAPACITY IN GALLONS: <br />11. TANK 9ONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D <br />A. Ea'l MOTOR VEHICLE "FUEL 2 PETROLEUM <br />B. <br />C. 1 UNLEADED ❑ 2 LEADED 3 DIESEL <br />Ej 3 CHEMICAL PRODUCT ❑ 4 OIL <br />�1 PRODUCT <br />❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br />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 & O.A.S. # A, C.A.S. #: AVA <br />Ill. TANK CONSTRUCTION MAR• ONLY :• <br />A. TYPE OF <br />❑ 1 DOUBLE WALLED <br />❑ 3 SINGLE WALLED WITH EXTERIOR LINER <br />® 95 UNKNOWN <br />SYSTEM <br />2 SINGLE WALLED <br />4 SECONDARY CONTAINMENT <br />99 OTHER <br />1 `STEEL/IRON <br />❑ 2 STAINLESS STEEL <br />®3 FIBERGLASS❑ <br />4 STEEL CLAD W/FIBERGIASSREINFORCED PLASTIC <br />B. MATERIAL <br />[:]5 CONCRETE <br />® 6 ,POLYVINYL CHLORIDE <br />❑ 7 ALUMINUM <br />F-18 100% METHANOL COMPATIBLE FRP <br />APPROVED BY NAME <br />E 9<BRONZE <br />E 10 GALVANIZED STEEL <br />❑ 95 UNKNOWN <br />99 OTHER <br />I RUBBER LINED <br />❑ 2 ALKYD LINING <br />� 3 EPDXY LINING <br />4 PHENOLIC LINING <br />C. INTERIOR <br />LINING <br />❑ 5 GLASS LINING <br />UNLINED <br />[:]"95 UNKNOWN <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />❑ YES ❑ NO <br />F� 99 OTHERLY2AA OTHERz <br />D. CORROSION <br />❑ 1' POLYETHLENE WRAP <br />® 2 TAR OR ASPHALT <br />❑ 3>NYL WRAP <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />Q 5 CATHODIC PROTECTION <br />E] 91 6NE <br />gpf 95 UNKNOWN <br />❑ 99 OTHER <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U 1F UNDERGROUND, BOTH 7F APPLICABLE <br />A. SYSTEM TYPE A U,1 SUCTIONA U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br />B. CONSTRUCTION A W-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 U 1 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP <br />A U 9 GALVANIZED STEEL A& 95 UNKNOWN A U 99 OTHER <br />LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br />P S 1 VISAL CHECK P' 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />P S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br />I. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1. ESTIM <br />THIS <br />T D DATE LAST USED (MO/YR) <br />2. ESTIMATED QUANTITY OF <br />3. WASTANK F ILED WITH <br />..SUBSTANCE REMAINI <br />INER M T L? ®YES E:] NO <br />FACILITY ID # <br />-GALLONS <br />RRECT. <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # <br />AGENCY # <br />FACILITY ID # <br />TANK ID # <br />CURRENT LOCAL AGENCY FACILITY ID # <br />APPROVED BY NAME <br />PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />PERMIT APPROVAL DATE <br />PERMIT EXPIRATION DATE <br />CHECK # PERMIT AMOUNT <br />BY: <br />SURCHARGE AMT. <br />FEE CODE RECEIPT # <br />FORM B (6-29-88) THIS FORM MUST BE ACCOMPANI <br />A FACIGTY/SITE KATION, <br />FOR A', UNLESS A ENT FORMA° HAS BEEN FILED <br />