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STATE OF CALIFORNIE WATER RESOURCES CONTROARD FORM ' ': UNDERGROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT olerHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 130 IV147fel.774e-001 31t FARM TANK-VES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID r:;- 1 B. MANUFACTURED BY: C YEAR INSTALLED LL '< D. TANK CAPACITY IN GALLONS: LLJ 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. p TOR CLE B. A ❑3 CHOEMICAL PIRODUCTL ❑4 OIL ROLEUM ry, FRODUCT C ❑4 GNASAHOL [—] 5 JET FUEL [—]6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY [—] 95 UNKNOWN I❑J 2� WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF - HAZARDOUS SUBSTANCE STORED 8 CAS.# C.A.S.#: MI.I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C.a D A. TYPE OF ❑ 1 DOUBLEWALIB) ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 5;j^ISINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEEUIRON ❑ 2 STAINLESS STEEL F] 3 RBERGUSB ❑4 STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-] 7 ALUMINUM ❑8109%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 1D0%METHANOL? ❑YES ❑NO ❑99 OTHER D.PROTECTION ❑ 5 CATHODIC PROTEECTION ❑91TNONE ARORASPHALT I Iw'"JUNKNOWNP Q 99 UCH SS REINFORCED PLASTIC IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 99 OTHER &, B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A W 95 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 C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WEEP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER i V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. { PS 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS V P 6 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH /� SUBSTANCE REMAINING IN INERT MATERIAL? E]YES ❑ NO /Q GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY I COUNTY# JURISDICTION# AGENCY# FACILITY ID N TANK ID N l 10 / I / SO © doa CURRENT LOCAL 3 AGENG FACILITY IDN APPROVED NAM OVED BPHONE#WITH AREA CODE Tdd/wV' a3 TIC. PERMIT NUMBER PERMIT APPROVAL DAYE PERMIT EXPIRATION DATE C CHECKN PERMIT AMOUNT �NRCHARGEANT. FEE CODE RFREIPTN BY: FORMB(3-7-w) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AC~ FORMA' HASSEENFILED DATA PROCESSING COPY