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...:.j�F..... _ ,......_ .. ....: -.. ..._... .-r s. . ;;,aFa ,... .�vr�j 't"rc�''F1'V��l' .,�...,.��aF+VFF° .�➢,�K�.+%' T"F v�'4: r yr., ,� STATE OF CALIFORNI WATER RESOURCES CONTROARD ty�':r°: NDEROUND STORAGE TANK PRO AM FORM B . U G �o TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. —^ '' z ID MARK ONLY F—] I NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 12 FACILITY/SITE NAME WHERE TANK IS INSTALLED: j 1 ara FARM TANK-YES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY -4 A. OWNERS TANK ID# � k MANUFACTURED BY: �'� C. YEAR INSTALLED f7 Q. TANK CAPACITY IN GALLONS: II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COWCETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. I UNLEADED ❑ DED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT F—] �rl 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.#: j III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 D E WALLED F—]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SIN WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F]6 POLYVINYLCHLORIDE F—] 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑ D LINING ❑ 3 EPDXY LINING F—]4 PHENOLIC LINING 'LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 9 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ElTA RASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 1 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U ys'9 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A eqqI5 UNKNOWN A 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A Lr 91 NONE C. MATERIAL A U 5 ALUMINUM AU CONCRETE A U 7 STEEL CLAD WIFRP A U B 100%METHANOL COMP�IATIBLE FRP A U 9 GALVANIZEDSTEEL A 05 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM Mf'IJST BE CIRCLED. P VISUAL CHECK S 2 1NVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WAT=R MONITORING WELLS P PRECISIONTESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST L15ED(MO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITF SUBSTANCE REMAINING IN INERT MATERIAL? ❑YE5 [7] NO GALLONS THIS FORM HAS B EN COMPI EYED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE.AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY F JURISDICTION# AGENCY# FACILITY ID# T aNK ID# r 51 1= AGENC ACILITY ID# APPROVED BY NAME PHONE#WH AREA CODE / F PERMIT NUMBER PERMIT APPROVAL DATE PERMIT#PI TION DAT r+ r CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FOHM B 16-29-881 THIS FORM MUST BE ACCOMPANIED E1Y A FACILITYISITE APPLICATION, FORM `A',UNLESS A C RRENT FORMA' HAS B EEN FILED DATA PROCESSING COPY