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R Or <br /> F CALIFORNI WATER RESOURCES CONTR( OARD <br /> STATS � <br /> FARM `B': UNDERGROUND STORAGE TANK PROGRAMo <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 10 <br /> MARK ONLY F-11 NEW PERMIT � 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION <br /> 7 PERMANENTLY CL USED TA K <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FARM TANK-YE5 NO W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: L , a,044 <br /> 1, TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (. f G 00 <br /> B. MANUFACTURED BY: <br /> A. OWNERS TANK ID# <br /> C. YEAR INSTALLED ` `T D. TANK CAPACITY IN GALLONS: <br /> N. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. n 1 MOTOR VEHICLE FUEL [-� 2 PETROLEUM <br /> B C. 1 UNLEADED 2 LEADED FA3 DIESEL <br /> El 3 CHEMICAL PRODUCT 4 OIL <br /> 1 PRODUCT 4 GASAHOL Q 5 JET FUEL 0 B AVIATION GAS <br /> 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 5 HAZARDOUS 80 EMPTY p 95 UNKNOWN <br /> 1), IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C A.S.# <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A.TYPE OF 9 99 OTHER <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT <br /> 1 STEEUIRON F-1 2 STAINLESS STEEL F-1 3 FIBERGLASS E] 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK �5 CONCRETE F-16 POLYVINYL CHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL 0 9 BRONZE ❑ 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR IJI 5 GLASS LINING � 6 UNLINED El 95 UNKNOWN <br /> LINING L� <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL9 YES 1:1 NO 99 OTHER <br /> D.CORROSION <br /> 1 POLYETHLENE WRAP F-] 2 TAO OR ASPHALT ❑ 3 VINYL WRAP K4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION �5 CATHODIC PROTECTION ❑ 91 NONE 0 95 UNKNOWN Ej 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A 1 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2'DOUBLE WALLED A 1�3 LYNED TRENCH A U 91 NONE A U 95 UNKNOWN A V 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A Q4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS(b S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAYNING IN INERT MATERIAL? YES NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> $ DATE <br /> APPLICANTS NAME(PRINT 0 6 NATURE) <br /> LOCAL AGENCY USE ONLY <br /> PENTCA#LA <br /> JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> 6 <br /> NCY FACILITY IDN <br /> APPROVED BY NAME, g7 PHONE k WITH AREA CODE <br /> 11 <br /> PERMIT APPROVAL DATE PE MIT EXPIRATION DATEPERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT N BY: <br /> IIIIIIIIIIIIIIIL <br /> FORM (6-29-88)f THIS FORM MUST BE ACCOMPANIED A FACILITYISITE APPLICATION,bmmmmmiiiiiii� FORM `A',UNLESS A ARENT FORM`A' HAS BEEN FILED <br /> JI II 1 [?� DATA PROCESSING COPY <br />