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WATER RESOURCES CONTR ARD <br /> STATE OF CALIFORNIA <br /> FORM W: UNDERGROUND STbRAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION =mom <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> �IIRO N.P <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM f/ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE Ej 8 TANK REMOVE' <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,:1��j s �/L� FARM TANK-YES E NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: �h <br /> �0 <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK C NTENTS IF(A.1),1 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. N <br /> A. L MOTOR VEHICLE FUEL PETROLEUM44 ce}' B. C. 1 UNLEADED � 2 LEADED IESEL <br /> Fi 3 CHEMICAL PRODUCT 4 OIL ('.tc �1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> El 5 HAZARDOUS 80 EMPTY [:] 95 UNKNOWN 2 WASTE El 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF , a <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# N6 C.A.S.#: <br /> I <br /> x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN j <br /> SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS F-1 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE 6 POLYVINYL CHLORIDE F-1 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE El 10 GALVANIZED STEEL 0 95 UNKNOWN ❑99 OTHER <br /> C.INTERIOR 1 RUBBER LINED �2 ALKYD LINING �3 EPDXY LINING �4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING F_�6 UNLINED5 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 0 YES NO [:]99 OTHER <br /> D.CORROSION ❑1 POLYETHLENE WRAP 2 TAR OR ASPHALT F-1 3 VINYL WRAP F-14 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:] 5 CATHODIC PROTECTION 91 NONE L4 5 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 0 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A 1SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE <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 GALVANIZED 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 /> r P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> f P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> 1-vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> j1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH <br /> . r SUBSTANCE REMAINING IN INERT MATERIAL? YES � NO <br /> ry GALLONS <br /> THIS FORM HA 4 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 /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> I <br /> L CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br />[ PERMIT NUMBER PERMIT APP A DTE PERMI EXPIRATION D <br />[ CHECK# PERMIT AMOUNT SURCHARGE AMT. /{Ra/y FEE CODE RECEIPT# BY: <br /> C <br />'t /,. <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMNIL101111 A FACILITY/SITE APPLICATION, FORM`A',UNLESS A RENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />