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STATE ,OF.;CAUFORNIA, WATER RESOURCES CONTROL BOARD 1, FOM UNDERGROUND UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION Y'.COMPLETE A SEPARATE FORM WITH THE FOLLOWING 10FORMATION FOR EACH TANK. z 10 MARK ONLY -❑ 1 NEW PERMIT. ❑3 RENEWALPERMIT SCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM .!`.❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 , C �1,2�`j2 �/ S7 FARM T(ANK-VES❑ NO'rTT N 1, TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C 9� CD A OWNERS TANK IDN B. MANUFACTURED BY: CL) C. YEAR INSTALLED - 0. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL ❑1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.N CA.S.E: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXA,B,C,LD A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SEOONOARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESSSTEEL ❑ 3 RBERGLASS ❑4 STEEL CLAD W/FISEFQASS(EINFORCED PLASTIC B.TANK MATERIAL 5 CONCRETE 6 POLYVINYL DORM 7ALUMMU B IW%IoHANOL COMPATIBLE FRP '.:_. ❑B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER C.INTERIOR ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑3 EPOAYUNING ❑4 PHFNOUCUNING LINING -. ❑ 5 GLASSUNING ❑ 6 UNLINED ❑95 UNKNOWN ❑ ISUNINGLUTERLALWATIBLEWRHIW%MMW40L7 YES []NO ❑99 OTHER . 0.CORROSION ❑ I POLYETHUMWRAP 2 TM OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 RBERGLASSREINFORCFDPUSTC PROTECTION -❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 LR4NNOKN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,90TH IF APPLICABLE A SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A V 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 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 A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 8 i VISUAL CHECK ► 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 S GROUND WATER MONITORING WELLS 16 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH - SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPUCANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION 3 N AGENCY 8 FACILITY ID N TANK ID# ' �` ; �-n CURRENT LOCAL AGENCY FACIL7y 10# APPROVED BY NAPE PHONE#WITH AREA CODE PERMITNUMBER _ PERYIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK( PERMIT AYUUMT SURCHARGE AMT. FEE CODE ECEIPT4 BY: � '� FORMB(6-29-891 THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESS CURRENT FORY'A' HAS RFFN LII FD