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STATE OF CALIFQRIV WATER RESOURCES CONTR OARD �'`�;°•�F"' <br /> FARM g'; UND RGROUND STORAGE TANK PRO ORAM <br /> TANK TANK PERMIT APPLICATION INFORMATION u,P <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT E 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> 1 C� <br /> ONE ITEM 2 INTERIM PERMIT F� 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED !7 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ae no w. (J t? FARM TANK-YES❑ NO Ej <br /> („p <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> F <br /> WNERS TANK ID# �TANK <br /> FACTURED'BY: oe'um4.S 1,L.'<ft.�EAR INSTALLED CAPACITY IN GALLONS: /0,000 <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,POMPLETE ITEM D. <br /> A. FTV MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F-1 4 OIL l//' PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS F� 80 EMPTY [-] 95 UNKNOWN Ej 2 WASTE 0 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.4 <br /> lll. TANK CONSTR CTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> F__] 1 STEEL/IRON F-] 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑ 5 CONCRETE F] 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR k' 15 GLASS LINING IJ 6 UNLINED 95 UNKNOWN <br /> LINING kkkk"'`____IIII <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES D NO E]99 OTHER <br /> D.CORROSION I POLYETHLENEWRAP 2 TAR OR ASPHALT F_� 3 VINYL WRAP FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER s'S <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> GA <br /> A. SYSTEM TYPE A U 1 SUCTION A V 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A6P 1 SINGLE WALLED AIW2 DOUBLE WALLED A 1p 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A W4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W1 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 /> S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MON ITOHING WELLS <br /> N� P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 5 95 UNKNOWN P 5 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> T1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLE�WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL �YES NO <br /> 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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> �CCOOUN�TYY## JURISDICTION# AGENCY# lo <br /> FACILITY ID# TANK ID# <br /> / -1 it ED 10 E <br /> 1 :1 F-1 I lo <br /> I lo F] <br /> CURRENT LOCAL AGENCY FACILITY ID# kPPROVED BY NAME PHONE#WITH AREA CODE <br /> NK 3 <br /> LERMIT NUMBER LAMT. <br /> OVAL DATE PERMIT EXPIRATIO' DATE <br /> ECK# PERMIT AMOUNT SURCHAFEE CODE RECEIPT# BY: <br /> `•� FORM B(6-29-as) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICANNIL <br /> ATION, FORM `A',UNI ESS A 4uARENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />