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STATE OF, I IIA"L WATER RESOURCES COT ARD <br /> U DE ROUND STORAGE TANKa <br /> TANK <br /> TANK PERMIT ALI TI INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: , 2cv r 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 /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,EOMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C• Effl UNLEADED 2 LEADED ❑ 3 DIESEL <br /> 3 CHEMICAL PRODUCT ® 4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL E]6 AVIATION GAS <br /> El 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.# A C.A.S.#: <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A,B,C,&D <br /> A.TYPE OF 1 DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT 0 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL • FIBERGLASS F-14 S EELCLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK IF-11 5 CONCRETE F-16 POLYVINYLCHLORIDE 7 ALUMINUM 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED F]2 ALKYD LINING EPDXY LINING 1:14 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING F�6 UNLINED ®95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES ❑ NO ❑99 0 ER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ® 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ® 95 UNKNOWN E:]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 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A?, 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A P8 <br /> 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 /> P $ 1 VISUAL CHECK P INVENTORY RECONCILIATION P S 3 VADOSE WELLS P $ 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISIONTESTING P 7 PRESSURETESTING 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? F-]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 /> I E( F/ <br /> .J <br /> CURRENTAAL CAL AGEY FACILITY ID# O D BY N E PHONE#WITH AREA CODE <br /> O t r <br /> lu <br /> PERMIT NUMBER PERMIT PPROV L PERMIT EXPIRATION DATE <br /> 1/ 7 <br /> CHECK# PERMIT AMOUNT SURCHARGE FEE CODE *RECEIPT# BY: <br /> IRM B(6-29-88) THIS FORM MUST BE ACCOMPANIM FACILITY/SITE KATION, FOR `A',UNLRENT FORMA' HAS BEEN FILED <br /> T_ PROCESSING COPY <br />