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STATE OF CALIFORNIA WATER RESOURCESCONTRO...4OARD FORM BF: UNDERGROUND STORAGE TANK PROGRAM #90557A TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION [:]7 PERMANENTLY CLOSED TANK ONE ITEM PERMIT LJ 2 INTERIM a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ff6 THANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Ron'S Personalized CheVTOn Service FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—BO SPECIFY A. OWNERS TANK ID N WC5718C B. MANUFACTURED BY: unknown C.YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 10,0 O allon- II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE REM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑X 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ®2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ® 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF P HAZARDOUS SUBSTANCE STORED&C A.S.N T; Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.E,C,a D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM O 2 SINGLE WALLED ❑4 SECONOARYCONTAINMENT ❑99 OTHERE wy!R(1 f`i\4 U� TlI I��, ❑ I STEEL/IRON ®2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGUISSREI J B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE RIP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOYM ❑%OTHER ❑ C.INTERIOR I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑A PHENOLIC LINING LINING ❑5 GLASS LINING ❑X 6 UTAINEO ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IRI%MEDIA1100 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETILENE WRAP ❑2 TAR OR ASPHALT ❑3 VIWL WRAP ❑1 FIBERGLASS REINFORCED PUSTIL PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A p 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A A 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 A U ISTEEL/IRON AO 2 STAINLESSSTEEL A U 3POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P O 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 6 A ELECTRONIC MONITOR P 1 5 GROUND WATER MONITORING WELLS ECI S 6 PRSION TES TING P 6 7 PRESSURE TESTING P 6 91 NONE P S %UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLEDWITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ElYES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY F PERJUR ,A D TOT~OMY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE DA410 &- o Sc+J - v 90 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N CILIIY^IDN TANK ID CURRENT LOCAL AO�[N/CY�F/AC�ILIT'IDN APPROVED NI BY NAME PHONE N WRDE H ARG CO C� IXV PLURAL,NUMBER IPERMR APPROVAL DATE PERMIT EKPNUITION DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORMB(629-89) THIS FORM MUST■MXVVAWn BTAFAummm AFFSK'ATIOM, FORM'A',UMLMACIMMR FOMM'M NASBEENFNED 1 DATA P.. CESSING COPY 2 LOCAL AGENCY CM -..d FRE COPY