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STATE OF CALIFORNIA! WATER RESOURCES CONTRA }OARD FORM'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY [( NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL K ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 0/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: r CA, FARM TANK - YES ❑ NO Pr nl�n vc.�ain icllvn WUMPLLIE ALL AIMS -IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID # + e. MANUFACTURED BY: ate/ C. YEAR INSTALLED I �' D. TANK CAPACITY IN GALLONS: / U DOO II. TANK CONTENTS IF IA.11. IS MARKED. COMPLETE ITEM C. IF MAT. 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❑'iPRODUCT ❑ 4 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 ) HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. B, C. A D A. TYPE OF ❑}-7�I� DOUBLE WAILED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM D ` SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A �SIEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL D WIFIBERGLSS REINFORCED PLASTIC F-1CLA B. TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 10AMETHANOLCOMPAPBLEFRP U 3 LINED TRENCH A U ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U/ F-11 RUBBER LINED ❑ 2 ALKYD LINING F-]3 EPDXY LINING E]4 PHENOUC LINING C. INTERIOR LINING ❑ 5 GLASS LINING V4 UNLINED A ❑ 95 UNKNOWN 5 ALUMINUM A A6 ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 PDLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASRC PROTECTION U�jl CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF AB EGROUND, U IF UNDERGROUND, BOTH IF APPLICABLE UANTITY OF A. SYSTEM TYPE A U 1 SUCTION A U PRESSURE A U 3 GRAVITY A U 99 OTHER AAERIAL? L CONSTRUCTION A U 1 SINGLE WALLED A V 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U% OTHER A U/ STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U d FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A A6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AUn95 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 6 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P46PRECISION TESTI P 8 ] PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER P46 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE a 1. ESTIMATEDATE LAST USED (MO/YR) 2. ESTIMATED UANTITY OF FACILITY ID # 16101 l6 1 3 1 s 3. WAST K FILLED WITH CUR:RETN LOCAL AGENCY FACILITY ID N �{��/. APP VEDBY AME SUBST AWING IN AAERIAL? ❑ YES [_NO PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT I SURCHAR E AMT. FEE CODE RECEIPT N cnAM A,, -,-FILO THIS FORM MAST RF ACCOMDAMIFD RV A FACII ITY/SITP ADDI ICATIDM FARSB IDI TIMI PS. RRFNT FORMA' NAS RFFN GALLONS �Vt�J`'�� THIS FdRM HAS BEEN COMPLETED UNDER PENALTY OFJPERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # [m] JURISDICTION k AGENCY # FACILITY ID # 16101 l6 1 3 1 s TANK ID # n o o i CUR:RETN LOCAL AGENCY FACILITY ID N �{��/. APP VEDBY AME PHONE# WITH AREA CODE PERMIT NUMBER PER IT APP OV 210 61 DA E b PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT I SURCHAR E AMT. FEE CODE RECEIPT N cnAM A,, -,-FILO THIS FORM MAST RF ACCOMDAMIFD RV A FACII ITY/SITP ADDI ICATIDM FARSB IDI TIMI PS. RRFNT FORMA' NAS RFFN BY: FII Fn DATA PROCESSING COPY 0 NJ