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STATE 1 WATER RESOURCES CNTR ARD $° ...:'�P <br /> S K TANK <br /> TANK PERMIT APPLICATIONINFORMATION <br /> COMPLETE ASEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1-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 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES Q 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. Gol MOTOR VEHICLE FUEL ® 2 PETROLEUM B. C. F-1 1 UNLEADED ;®2 LEADED DIESEL <br /> 3 CHEMICAL PRODUCT F-�4 OIL 1 PRODUCT, ❑4 GASAHOL ®5 JET FUEL D 6 AVIATION GAS <br /> 5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ®2 WASTE ❑7 METHANOL ®99 OTHER(DES RIBE 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 CONSTR.UCTION MARK ONE ITEMONLY IN x A,B,C,a D <br /> A TYPE OF 1DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ®95 UNKNOWN <br /> SYSTEM ®2 SINGLE WALLED 4 SECONDARY CONTAINMENT a 99,2!R- <br /> 1 <br /> 90R1 STEEL/IRON ®2 STAINLESS STEEL ®3'FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ®r5,CONCRETE ®6 POLYVINYL CHLORIDE 7 ALUMINUM 8 10096 METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE ® 10 GALVANIZED STEEL Q 95 UNKNOWN ❑99 OTHER <br /> C.INTERIOR ®1'RUBBER LINED &'6 <br /> LINING 3 EPDXY LINING ®4 PHENOLIC LINING <br /> LINING ®5 GLASS LINING MED W?OTH <br /> KNOWN <br /> ® IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:]NOER AOL <br /> D.CORROSION ❑1 POLYETHLENE WRAP F�2 TAR OR ASPHALT ®3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E:]`5 CATHODIC PROTECTION [:]91 NONE ❑95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMARON CIRCLE A IF ABOVE GROUND,-U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TM AU T SUCTION A M42 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 UV2 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 Y,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 f U 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 SEC=,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P "S 1 VISUAL CHECK P S' 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSW4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMAT DATE LAST USED(MO/YR) 2. ESTIMATE QUANTITY OF 3.WAS TANKfILLED WITH <br /> SUB&NE EGALLONS <br /> MAINING IN INER IAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED E,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 /> l <br /> ICHE <br /> RENT LOCAL AGENCY FACILITY ID# APPROVED BY NAM PHONE#WITH AREA CODE <br /> A rjzgQ' I I //A/915 <br /> MIT NUMBER PER VAL D MIT PIRA ION DATE <br /> It <br /> CK## PERMIT AMOUNT $URCHARG AMT. FEE CODE RECEIPT <br /> 3 <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMP A FACT CATION, FORM`A',UNLESS RRENT FORMA' NAS BEEN FILED <br /> DATA, Y <br />