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STATE OF CALIFORMA WATER RESOURCES CON L BOARD FORM W: U RGROUND STORAGE TANK PR TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT .- ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ❑ ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE L�°TANK REMOVED a, FACILITY/SITE NAME WHERE TANK IS INSTALLED: L YQ/M � t 22f S HLvY94' FARM TANK-YES❑ NO �. I. TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY a"oeN/C'it A. OWNERS TANK ID# Arss -Z' B. MANUFACTURED BY: fA ft-li C. YEAR INSTALLED D. TANK CAPACIN IN GALLONS: � D000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. �41 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED J&;&RESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL �`1 PRODUCT ❑ 4 GASOHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY E] 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,8 D A. TYPE OF �❑!I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN 1p SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMEM ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL. ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 1W%METHANOL OOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL (.#5 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 AWD LINING ❑3 EPDXY LINING /�❑1�/4��PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED T�UNKNOWN ❑ISLINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES E]NO OTHER::LAg/ D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP (L(L(L---��---��(((///4 FISERGLASSR I ED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE �95 UNKNOWN � OT fl IV. PIPING INFORMATION CIRCLE IFA13OVE GROUND, U IFUNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A U / SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 05 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 A(U,;b5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE TVCI A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A,U U-�6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A( /9S 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 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TERTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI MATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITYOF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Lo10 � � 6 000 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE o K) G lei (t lre— PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE CXECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# �`V" FORM B(e-29-881 THIS FORM MUST BE ACCOMPANIt BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY ' '�