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STATE OF CALIFOR& WATER RESOURCES CONAk BOARD FORM 18': UNOERGROUNI) STORAGE TANK PROGRAM 'mit /j` Tw " TANK PERMIT APPLICATION INFORMATION : i ~� COMPLETEi A kPAR00 FONM WITH 1HI!FOLLOWING INF_C NMATION FON EACH TANK. .• MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT CHhNOE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I ONE ITEM ❑2 INTERIM PERMIt ❑/AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ❑R TANK REMOVED fACM.ITYMITE NAME MHERE LANK 16 INSTALLED: .- f= s S /t, / FARM TANK-YES❑ NO ❑ C 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY J A. OWNERS TANK IDM y' S. MANUFACTURED BY: �.�/� c C. YEAR INSTALLED � •Z_. D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. _ C. ❑ I UNLEADED U 2 LEADED c 1ESEL ❑3 OlkVICAL PRODUCT ❑A OIL 0-1-PRODUCT ❑ A GASAHOL ❑5 JET FUEL ❑R AVIATION CAS ❑5 HAZARDOUS ❑RO EMPTY n 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.RFUOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.E CA S.F: III. TANK CONStRUCVON MARK ONE ITEM ONLY IN SOX A,S,C,S D A TYPE OF 1 I)MI'ALLM ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SY/TEM 2 WAll.EO ❑1 SECONDARY CONTAINMENT ❑99 OTHER 1 mm ❑2 SIAIAESSSTEEL ❑3 FIBERGLASS ❑1 STEEL CLAD WIRBECiIASS REWORDED PLASTIC D.TANK S COmmm 1 PGVWNYL OAOROJE 1 ALUMINUM MATERIAL ❑ ❑ ❑ ❑9 IOOMMETIMNOLCOMPATIBLEFRP ❑9 RROII2E ❑ 10 GALVANIZED STEEL ❑95 UWR M'N ❑99 OTHER C. ONERION ❑1 R BSER LINm ❑1 LINING ❑0 EPDXY LINING L] 1 PHENGIC LIMNO LOPING ❑S GAS9LNN(9 1 U ZIMR) ❑95 UNKNOWN ❑1LNRE9MA7ERALCOMPAIV9LEWITH1001LMETHANOLS ❑YES ❑No ❑99 OTHER D.CORROSION ❑ 1 PGYEIIAENEWRLP ❑2,W OR ASPHALT 3 MYLWRAP [:] 9 RREn(WASSBERIFoRCEDPIASTIC PROTECTION ❑S CATHODIC PAOFECTION ff9I NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A STORM TYPE A u I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A5 LANK _ A U 99 0111ER 1.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AK 95 UNKNOWN U 99 OTHER A- U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPL ••- A V 91 NONF G -S MATERIAL TU' "ALUM�NUUM A U B CONCRETE A U 7 STEELCLADW/FRP A U B 100%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 S 1 INVENTORYRECONCILIATION P WELLS P IA_A_ ATRONIC MONITOR P S 5 OROUND WATER MONITODINO WFLLS P S S FRECNION TESTING P S T PRESSURE TESTING 1 91 NONE l P S 95 OWN , P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L EST HAA TED DATE LAST USED IMO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES El No THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PMNTED 6 91GNAtURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION A AGENCY 9 FACILITY ID R TANK ID 1 C ' L�n"VWWrLOCALENCT FACKITY M 1 APPROVED SLit T NAME PHONE E WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT 1 IlyRio FORM R(Ra9.RR) THIS FORM WAR'1E ACCOMPANIED 1Y A FACILIt991ITE APPLICATION, FORM 'A',UNLEIS A CURRENT FORM'A' HAS SEEN FILED b IA nEOD,un n......