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STATE OFCALIFORNI& <br /> WATER RESOURCES CO T g° °•,'N� <br /> UNAMROUND STORAGE TANK <br /> PROMwFORM <br /> e a <br /> * w <br /> TANKTANK PERMIT APPLICATIONINFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> I <br /> MARK ONLY R1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT ®4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED OR <br /> FACILITY/SITE NAME WHERE TANK 7S INSTALLED: ® 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. TANK2ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL ® 2 PETROLEUM B. C. F-] 1 UNLEADED 2 LEADED ®3 DIESEL <br /> ® 3 CHEMICAL PRODUCT F__] 4 OIL /, PRODUCT ®4 GASAHOL F_� 5 JET FUEL ®6 AVIATION GAS <br /> 5 HAZARDOUS 1:1 80 EMPTY 0 95 UNKNOWN Ej 2 WASTE ®7 METHANOL 0 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 /> III. TANK CONSTR22TION MARK ONE ITEM ONLY IN sox A, ,C,&D <br /> A.TYPE OF FFrl DOUBLE WALLED F_�3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM 0 2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑99 OTHER <br /> 1 STEEL/IRON ❑2 STAINLESS STEEL ®3 FIBERGLASS F-]4 ST EL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE ® 7 ALUMINUM 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL ❑ 95 UNKNOWN ®99 OTHER <br /> 1 RUBBER LINED ®2 ALKYD LINING EPDXY LINING F-]4 PHENOLIC LINING <br /> C.INTERIOR <br /> F-]LINING 5 GLASS LINING [:]6 UNUNEO F-]95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ®YES ❑ NO 0 99 THER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ® 2 TAR OR ASPHALT ®3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION F-1 5 CATHODIC PROTECTION [::]91 NONE 95 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 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 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A 0 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> ------------ <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S INVENTORY RECONCILIATION P S 3 VADOSE WELLS 49S 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. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F-]YES E NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> Ll I I U a <br /> I o' il LZ <br /> JPERMIT <br /> RRENT LOCAL AGENCY FACILITY ID# APPR D BY NAME PHONE#WITH AREA CODE <br /> r <br /> NUMBE PERMIT APPROVAL A PERMIT EXPIRATION DATE <br /> 1 <br /> ECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMP A FACILYfY/SITE ICATI , F ` 79 UNLESS URRENT FORM`A' HAS BEEN FILED <br /> T ,'PROCESSING <br />