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STATE OF CALIFORN WATER RESOURCES CONTRIVOARD FORM 'BLA ': ND GROUND STORAGE TANK PR RAM TANK COMPLETE PERMIT APPLICATION I FORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWI FORMATION FOR EACH TANK. z MARK ONLY ❑ 1 EW PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED T NK !O ONE ITEM 2 / INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / IV FACILITY/SITE NAME WHERE TANK IS INSTALLED: S9. t4 Ce uJ- FARM TANK-YES❑ NO 416 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1-� CD A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED ` D. TANK CAPACITY IN GALLONS: 14 0 fJ II. TANK 96NTENTS IF(A.1),IS MARKED,COMPLETE IT C.IF(A.1),IS NOT MARKEDIZOMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT E]4 OIL PRODUCT ❑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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF DOUBLE WALLED ❑3 SINGLE WALLED NTH EXTERIOR U ❑95 UNKNOWN SYSTEM 2 INGLE WALLED ❑4 SECONDARY CONTAINMEM 99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 IDA METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER UNED ❑2 ALKYD LINING 3 EPDXY UNING V99POUGTHER ENOLICUNING LINING ❑5 GLASS LINING E]6 UNUNED NKNOWNIS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT 0 34NYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE L 995 61NKNOWN ❑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 V 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U %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 fi CONCRETE A U 7 STEEL CLAD WEEP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS OPh: 6 PRECISION TESTING 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® = 160h Fl-T6 101001 CURRENT LOCAL AGENCY FAC ITY IDN APPROVED BY NAME PHONE#WITH AREA CODE ERT0 ( PERMIT NUMBER PERMIT APPROVA4 DATE PERMIT EXPIRATION DATE CHECKM PERMIT AMOUNT -URCHARGE AMT. fFEE CODE ^ CEIPT# BY: FORM B(6-29-8B) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY