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77177 ITT-1 777- <br /> STATE OF CALIFORN WATER RESOURCES CONT OARD <br /> _� <br /> F U S TNKPROGRAM <br /> : <br /> TANK PER ITSTI INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -F�R- <br /> I <br /> MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM E]2 INTERIM PERMIT 4 AMENDED PERMIT ®6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED Q) <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 229 FARM TANK-YES❑ NO <br /> I. 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 /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. E216MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. 1 UNLEADED 0 2 LEADED 3 DIESEL <br /> 3 CHEMICALPRODUCT ❑ 4 OIL PRODUCT E]4 GASAHOL F 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY [:] 95 UNKNOWN ®2 WASTE 1:1 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.# C.A.S.#: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLYIN Box A,B,C,&o <br /> A.TYPE OF DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ®4 SECONDARY CONTAINMENT 99 OTHER <br /> ® 1 STEEUIRON 2 STAINLESS STEEL FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ®6 POLYVINYLCHLORIDE ® 7 ALUMINUM ®8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> Q 9 BRONZE 10 GALVANIZED STEEL ®95 UNKNOWN [:]99 OTHER <br /> 1 RUBBER LINED F-12 ALKYD LINING ®3 EPDXY LINING �4 PHENOLIC LINING <br /> LINING <br /> C.INTERIOR 5 GLASS LINING NLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ®NO ❑99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ®4'FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION D 5 CATHODIC PROTECTIONNONE ®95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TWE A U 1 SUCTION AU 2 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 U)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/6/4 FIBERGLASS PIPE A U 91 NONE <br /> / C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD'W/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 /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSP S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECI!ION 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 QUANTITY OF 3.WAS TANK FILLED WITH <br /> fJ SUBSTANCE REMAINING IN GALLONS I <br /> INERT MATERIAL? YES E] 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 /> 19 � 9] , Ll I I <br /> CUWRENT LOCAL AGENCY FACILITY ID# APPROV BY NAME PHONE#WITH AREA CODE <br /> uulk� Ah <br /> MIT NUMBER PERMIT APPROVAL DATE PE 1 PIRA NDA <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> r <br /> FORM a(6-29-B6) THIS FORM MUST BE ACCOMPANI A FACILITY/SITE LICATION, FOR `A',UNLESS RENT FORM"A' HAS BEEN FILED <br /> T I Y <br />