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STATE OF CALIFORNI WATER RESOURCES CONTR ►RD FORM W: UNDE&GROUND STORAGE TANK PRAM rn`' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN NFORMATION FOR EACH TANK. Z 3 RENEWAL PERMIT MARK ONLY ❑ 1 NEW PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTL 10 ❑ ❑ Y r ONE ITEM 1:12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEI �O FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO ❑ N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY IJ/� G/J -95Z 410 A. OWNERS TANK ID# B. MANUFACTURED BY: V K� �I C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS' K,,, II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑ i UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY 5 UNKNOWN ❑2 WASTE El METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.AS.# C.A.S.a: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER El STEBUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL El5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 A�LLMllbM ❑8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL E&eUNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 P 'LIC LINING C. INTERIOR LINING ❑5 GLASS LINING ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1D0%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ i POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT3 ❑ _PL ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 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 fi5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FI RGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A CONCRETE A U 7 STEEL CLAD WEEP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE S 5 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' E]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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY 10# TANK ID# / / 1610 lo CURRENT LOCAL AGENCY FACILITY ID // APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / I l�JCHECK# PERMIT AMOUNT I SURCHARGEAMT. FEE CODE RECEIPT BY: V FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A`,UNLESS A CURRENT FORMA NAS BEEN FILED DATA PROCESSING COPY