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9^ ; STATE OF CALIFORN WATER RESOURCES CONTRC IOARD FORM B': UNDE GROUND STORAGE TANK PRd RAM TANKTANK PERMIT APPLICATION INFORMATION H TANK. ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACZ 1 O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 15 CHANGE OF INFORMATION [-] 7 PERMANENTLY NK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE . FACILITY/SITE NAME WHERE TANK IS INSTALLED: #AAA&J1 � FARM TANK-YES Y NO ❑ CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY f-14140CD A. OWNERS TANK ID R B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS 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 ❑ BO 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&C.A.S.# C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.8 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERG 4 SEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑6 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 INUM F-1 B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE E] STE 10 GALVANIZED EL UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2ALKYD UNING ❑3EPDXY LINING ENWCLINING C.INTERIOR ❑6 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERAL COMPATIBLE WITH 10096 METHANOL? ❑YES NO ❑ 99 OTHER D. CORROSION F-1I POLYETHLFNE WRAP ❑ 2 TAO OR ASPHALT ❑/""'LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 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 JAOS UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELU 5 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 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P LECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLAbf 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE ` LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY N FACILITY ID# TANK ID# CURRENT LOCAL A ENCY FACILITY IDM APPROVED BY NAME PHONE N WITH AREA CODE �c n�� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 124 ICMECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY:,( FORM 6(6-29-33) THIS FORM MUST BE ACCOMPA'lft BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESrrCURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _