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STATE OF CALIFORNIib WATER RESOURCES CONTROOARD <br /> FORM BN: UNDE ROUND STORAGE TANK PRO AM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDT K <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' i I W FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SOSPECIFY <br /> A. OWNERS TANK ID# I B. MANUFACTURED BY: UCD <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 6 6 O <br /> II. TANK CONTENTS 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. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ OIL ❑ 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS <br /> 5 HAZARDOUS ❑ BO PTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTERME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A. .R C.A.S.N: <br /> III. TANK CONSTRUCTION MARK 0\4 ITEM ONLY IN BOX A,B,C,&D <br /> A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 INGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 S NOARi CONTAINMENT ❑99 OTHER <br /> ❑ i STEEL/IRON ❑2 STAINL STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK ❑ 5 CONCRETE ❑6 POLYVINY HLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOLCOMPATIBLEFRP <br /> MATERIAL <br /> 9 BRONZE ❑10 GALVANIZE TEEL ❑ 95 UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ i RUBBER LINED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLBIE WRAP ❑2 TAR OR ASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUN RGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U\3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U \99THER <br /> YVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U S ALUMINUM A U B CONCRETE A U EL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECOND Y,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLSP S ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 NKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> i. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED DUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO <br /> O ONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY IDR TANK ID# <br /> bo 111 � M I s 1 1 b00 � <br /> CURRENT LOCAL AGENCY FACILITY ID "PROVED BY NDE PHONE N WITH AREA CODE <br /> Moore Lf L/ <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERIAITEXPIRATION DATE <br /> 1 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> V✓J FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIE YA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA HASBEENFILED <br /> �\'\ DATA PROCESSING COPY <br />