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STATE OF CALIFORN10 WATER RESOURCES CONTRARD �A 4 � a FARM B ; UNDERGROUND STORAGE TANK PRO AM TANK PERMIT APPLICATION INFORMATION TAN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMA MARK ONLY TION 7 PERMANENTLY CLOSE K ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Al/ � S7�,d FARM TANK-YES❑ NO rN I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# =TANK ED BY: C. YEAR INSTALLED EE TY IN GALLON&: 1iv 5-67 IL TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),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 PRODUCT ❑ 4 GASAHOL ❑ 5 FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BD 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.# CIt/ III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ OUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WFFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE Ej 71MINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL H95 UNKNOWN ❑ 99 OTHER F--] 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING ❑ 4 ENOUC LINING C. 114TERIOR ❑ 5 GLASS LINING ❑6 UNLINED �95/KNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES NO 99 OTHER D. CORROSION ❑ 1 POLYETHIENE WRAP ❑ 2 TAR OR ASPHALTV995UNKNOWN WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE OUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 91 NONE A 95 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL Ao 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION p 8 3 VADOSE WELLS4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P P 8 6 PRECISIONTESTING P 5 7 PRESSURETESTING P S 91 NONE P 95 UNKNOWN P 5 99 OTHER y VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF T3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? EYES ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY FLLOCAL JURISDICTION# AGENCY# FACILITY ID# TANK ID# - - I ' l 1010 � � V) I F;�TololZl CY FACILIT ID# APPROVED BY NAME PHONE#WITH AREA CODE lP PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 3 CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT# 7 BY M B 6-29-66 THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNLESS A CURRENT FORMA' HAS BEEN FILED FORM { ) DATA PROCESSING COPY