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STATE OF CALIFORMA WATER RESOURCES CONTROL BOOAAR_D� FORM AB': UNDERGROUND STORAGE TANK OGRAM TANK :" .TANK P RMIT PPLI ATION I ORMATION OMPLE SEPARA RM WITH THE fOLLOWING I FORMATION FORE CH TAN MARK ONLY I NEW PERMIT O REN PERMIT ❑5 HA GE OF INFORMATION 7 PERMANENT p ONE ITEM ❑ INTERIM PERMIT'S AMENDED PERMIT ❑ 6 TE RAW TANK CLOSURE ❑S ANK I'7 FACILITY/SITE NAME WHERE TANK 15 IN GALLED: 7c2 L- (L F-� YZ FARM TANK-YES NO L I. TANK DESCRIPTION\QOM TE ALL ITEMS-IF UNKNOWN-80 FY A OWNERS TANK 10 8 B. MANUFACTURED BY: C.YEAR INSTALLED O. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM To C. ❑ I UNLEADED ❑ 2 LEADED ❑ 0 DIESEL 0 CHEMN:AL PRODUCT / OIL PRODUCT ❑ OASAHOL 5 JET NEL e AVIATION GAS EIS HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWNWASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.I C.A.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A D A TYPE OF ❑ I DOUBLE WAILED ❑0 SINGLE WAILED WITH EXTERIOR LOU ❑95 UNKNOWN SYSTEM ❑2 SINMEWAIIEO 1 SECONDARY CONTAINWNT ❑99 OTHER ❑ I STEEL" ❑2 STAINLESSSIEEL ❑ 7 FIBERIXASS ❑1 STM CUD WIFIBERGLASS REINFORCED PLASTIC B.TANKEl 5 CONCFETE ❑ 5 POLYVINYL OLORDE ❑ 1 ALUMINJM ❑N l9D%METHANOL.COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL [].95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I IIUBBERUNE0 ❑2 ALM LINING �S EPDXY UNNG ❑/PHENOUCUMNG LINING ❑5 GLASSUMNO ❑S L LINED ❑95 Uwcn ❑ IS LINING MATERIAL COMPATIBLE WITH 100%MONISM? [:]YES ❑ NO ❑99 OTHER D. CORROSION ❑ I PCLYUR-MWRAP ❑2 TAR ORASPHALT ❑7 AWL WRAP ❑ 1 FISERGU9S REINFORCED PUS TIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNO'AN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U S GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U O LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U S POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U B CONCRETE A U I STEEL CLAD W/FRP A U 9 I00%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 • I VISUAL CHECK P 5 2 IMEN70RY RECONCILIATION P B 0 VADOSE WELLS P B A ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P 9. 0 PRECISION TESTING P f 7 PRESSURE-TESTING P 9 91 NONE P t 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OFGALLONS 1 WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYF JURISDICTION E AGENCY[7[ # �I FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE A WITH AREA CODE ova � L ✓t;' r-2 D' PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMITAMOUNT URC MARGE AMT. FEE CODE ECEIPTA