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STATE OF CALIFORN WATER RESOURCES CONTR&BOARD Qp <br /> FORM ` UNDERGROUND STORAGE TANK R (MRA <br /> TANK TANK PERMIT APPLICATION I z <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED C.V <br /> ONE ITEM 2 INTERIM PERMIT El 4 AMENDED PERMIT _ <br /> FARM TANK-YES❑ NO („V <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: . Gly / C.TI <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK IDN # <br /> B. MANUFACTURED BY: ak— <br /> D. TANK CAPACITY IN GALLONS: (J` <br /> ,1 oov <br /> C.YEAR INSTALLED L <br /> II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. ❑ 1 UNLEADED 2 LEADED E]3 DIESEL <br /> A. 1 MOTOR VEHICLE FUEL "2 PETROLEUM <br /> 3 CHEMICAL PRODUCT � 4 OIL <br /> RODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS E]80 EMPTY []95 UNKNOWN 2 WASTE 0 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF U /, C.A.S.N: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N Iv <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D <br /> A TYPE OF ❑ 1 UBLE WALLED 381NGLE WALLED WITH EXTERIOfl LINER 95 UNKNOWN <br /> SYSTEM W 2 6 LEWALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> i STEEL/IRON 2 STAINLESS STEEL M 3 FIBERGLASS 4 STEELCLADW/FIBERGIASSREINFORCED PLASTIC <br /> B.TANK � 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM B 1Do%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE ED 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYO UNING El 3 EPDXY LINING n+PIJENOUC LINING <br /> C. INTERIOR 5 GIASSUNING 6 UNLINED k 5 UNKNOWN <br /> LINING ED <br /> IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? �YES �NO 99 OTHER <br /> ---------------- <br /> D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TARORASPHALT 3 VI WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION D 91 NONE UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 9 NKNOW A U 99 OTHER <br /> B.CONSTRUCTION tALUMINUM <br /> E WAL D A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A L(-9=OWN OWN A U 99 OTHER <br /> /IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISERG SS PI A U 91 NONE <br /> C. MATERIAL A U A U 6 CONCRETE A U 7 STEELCLADW/FRP A U S 100%METHANOL COMPATIBLE FRP <br /> A UNIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYST CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> p S 1 VISUAL CHECK -- T,ON P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MOIVR) 2.ESTIMATED OUANTIN OF INERT MATERIAL? YES NO <br /> SUBSTANCE REMAINING IN GALLONS <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 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N <br /> 7TANKID <br /> CURRENT LOCAL AGENCY FACILITY ID N <br /> APPROVED BY NAPE PHONE N W <br /> �]]. y /G 1.2 <br /> /)/vIq PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE p� <br /> O' <br /> CHECK I PERMIT AMOUNT SURCHAR AMT. FEE CODE RECEIPTIN BY: /d /,3 / <br /> FORM B(6-29-66) THIS FORM MUST BE ACCO ANIEO BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />