Laserfiche WebLink
STATE OF CALIF WATER RESOURCES CONTBOARD <br />FORM V: LIND GROUNDSTORAGETANKPROGRAM <br />TANK TANK PERMIT - APPLICATION7FOR <br />RMATION <br />COMPLETE A SEPARATE FO WITH THE FOLLOWINMATION FOR EACH TANK. <br />MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION r -j 7 PE <br />ONE ITEM ® 2 INTERIM PERMIT 4 AMENDED PERMIT ® 6 TEMPORARY TANK CLOSURE F-1 8 TA. <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: I 6A`I ARM TAP <br />'ANK DESCRIPTI011 COMPLETE ALL ITEMS - IF UNKNOWN - SO SPEIFY / <br />A. OWNERS TANK ID #B. MANUFACTURED BY: <br />C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br />rANK ®NTENTS IF /A 11_ IS UARKFn CAYDI RTP ITou P Ie to tl to unr <br />YES <br />A. 1 MOTOR VEHICLE FUEL F-1 2 PETROLEUM <br />BiKi <br />C. 1 UNLEADED 2 LEADED � 3 DIESEL <br />3 CHEMICAL PRODUCT � 4 OIL <br />PRODUCT <br />4 GASAHOL F-� 5 JET FUEL Ej 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 & C.A.S. # C.A.S. #: <br />111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 80X A. B. C. & D <br />In <br />A. TYPE OF <br />❑ I 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 />B. CONSTRUCTION <br />I STEELARiON <br />2 STAINLESS STEEL <br />® 3 FIBERGLASS <br />4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />B. TANK <br />MATERIAL5 <br />CONCRETE <br />6 POLYVINYLCHLORIDE <br />® 7 ALUMINUM <br />8 100% METHANOL COMPATIBLE FRP <br />1 STEEL/IRON <br />9 BRONZE <br />El 10 GALVANIZED STEEL <br />® 95 UNKNOWN <br />99 OTHER <br />C. INTERIOR <br />i RUM LINED <br />[:]2 ALKYD LINING <br />® 3 EPDXY LINING <br />4 PHENOLIC LINING <br />LINING <br />❑ 5 GLASS LINING <br />F-16 UNLINED <br />6 100% METHANOL COMPATIBLE FRP <br />❑ 95 UNKNOWN <br />A U <br />IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />® YES ® NO <br />99 OTHER <br />D. CORROSION <br />❑ I POLYETHLENE WRAP <br />2 TAR OR ASPHALT <br />® 3 VINYL WRAP <br />4 FIBERGLASS REINFORCED PLASTIC <br />PROTECTION <br />E] 5 CATHODIC PROTECTION <br />91 NONE <br />® 95 UNKNOWN <br />® 99 OTHER <br />. Ill INN tr4rt KMA I IUN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />SYSTEMA. TYPE <br />A U <br />1 SUCTION <br />A <br />U 2 PRESSURE <br />A <br />U 3 GRAVITY A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />B. CONSTRUCTION <br />A U <br />1 SINGLE WALLED <br />A <br />U 2 DOUBLE WALLED <br />A <br />U 3 LINED TRENCH A U 91 NONE <br />A U 95 UNKNOWN A U 99 OTHER <br />A U <br />1 STEEL/IRON <br />A <br />U 2 STAINLESS STEEL <br />A <br />U 3 POLYVINYL CHLORIDE (PVC) A U <br />4 FIBERGLASS PIPE A U 91 NONE <br />C. MATERIAL <br />A U <br />5 ALUMINUM <br />A <br />U 6 CONCRETE <br />A <br />U 7 STEEL CLAD W/FRP A U <br />6 100% METHANOL COMPATIBLE FRP <br />A U <br />9 GALVANIZED STEEL A <br />U 95 UNKNOWN <br />A <br />U 99 OTHER <br />V. LEAK DETECTION SYSTEM STEM mmni F D 1:/10DO11AADV nO a <br />P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />P S 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. ESTIMATEDIDATE LAST USED (MO/YR) <br />2. ESTIMATED QUANTITY OF <br />3. WAS TANK FILLED WITH <br />SUBSTANCE REMAINING IN <br />INERT MATERIAL? D YES [:] NO <br />-GALLONS <br />1 "to ru? en nna oCCIV L.UMYLt I cU UNUtH PtNAL7 Y OF PERJURY. AND TO THF RFRT OF MY KNOW) EDG17 IQ Tal IC a AID COOD 7 <br />APPLICANT'S NAME (PRINTED & SIGNATURE) DATE <br />L®CAL AGE <br />COUNTY# <br />CURRENTLOCAI <br />PERMIT NUMBER <br />W <br />CHECK # <br />USE ONLY <br />JURISDICTION # <br />L - LA -1 <br />:VIACILITY ID # _ , 7 <br />PERMIT AMOUNT <br />FORM B (6-29-68) THIS FORM MUST BE ACCOMPANIED <br />AGENCY # FACILITY <br />ID # TANK ID # <br />La- I L FT i <br />APPROVED BY NAME PHONE # WITH AREA CODE <br />PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br />SURCHARGE AMT. FEE CODE RE W 'T # BY <br />0 is <br />A ACILITY/SITE APPLICATION, FORM W, UNLESS A CURRENT FORMA' HAS BEEN FILED <br />DATA PROCESSING COPY <br />