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E STATE OF CALIfFORNU,e .' .' WATER RESOURCES CONTRO.,.;OARD UNDERGROUND STORAGE TANK PROGRAM .��, ` N - TANK PERMIT APPLICATION INFORMATION ` '�' '• - µ` UPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. � _',a',i `' 111ARK'ONLY.:,+•,,_,❑1 NEW PERMIT ;: ❑3 RENEWAL PERMR> 5 CHANGE OF INFORMATION ❑ 7 PEAMAHENTLY CL K ;ONE ITlEM';t, ❑2 INTERIM PERMIT,. ❑4 AMENDED PERMIT ❑B TEMPORARY TANK CLOSURE ❑B TANK REMOE- FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q FARM TANK-YES O ❑ f V �:.TANK DESCRIPTION' COMPLETE ALL ITEMS-IF UNKNOWN---!SO SPECIFY 1 ([) r A 'OWNERS TANK 1D M B. MANUFACTURED BY: C.YEAR,INSTALLED , D. TANK CAPACITY IN GALLONS: Q 'TANKPONTENTS IF(A.1),IS MARKED,COMPLETE ITEM CAF(A-1),1S NOT MARKED.COMPLETE ITEM D. A. 1 MQTOA VEHICLE FU0. ❑2 PETRQLEUM 8.' C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL £[ ❑3 CHEMK;AL PRODUCT' ❑ 4 OILppOD( T j❑4 GASAHOL ❑ 5 JE7 FUEJ ❑ 6 AVIATION GAS [:]'5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM 0,BELOW) D. IF NOF MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.t. `! C.A.S.I: III. TANKCONSTRUCTION MARK ONE ITEM ONLY IN Box A.B,C.A D I 3 SINGLE WALLED WITH EKTEWOR UNIER 95 LINKNowN A.TYRE OF ❑ DWM WALL®, ❑ ❑r SYSTEM. ❑2 SINGLEWALED 4 SECON WIYCONTANBIENT 99 OTHER ' ❑I srmi i0N 2 STM.ESSSFEEL ❑3 RBEAGIM STEELCLADW/FN)EW4=FEINFORCEDPUASAC B.TANK ❑5 CONCRETE ❑6 POLYYMIR.CHLORIDE ❑'7 ALUMINUM ❑6 10091 METHANOL COMPATIBLE FRP MATERIAL.: ,....;❑9 BRONZE ❑ 10 OALYANIZEO STEEL ❑.95 UNKNOWN ❑99 OTHER C.11=1011 ❑ I RUBBER WO ❑2 ALKYD Ll" ❑3 EPOKY LHNG ❑ PHENOLIC UN IND LINING : ,. ❑5 0LA53LNINq ❑e 1p6.INFD ❑95 UNKNOWN Q IS�NW MATe I&COIRATN3LEWITH .YM ❑NO []`99 aTHER D.CORROSION . ❑.I.AOUYETHI ENE WARP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ FlBERGLASS REINFORCED PLASTIC PROTECTION: ❑5 CATHODIC PROTECTION ❑91 NOW ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE a. . A.SYSTEM TYPE A U 1 SUCTION' A U 2 PRESSURE ' A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTI4ER 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 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE Q MATERIAL'' A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U B GALVANIZED STEEL A U 95 UNKNOWN A U 98 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S.FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 81 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P i 3 VADOSE WELLS P 111 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS P 9 6 PRECISION TESTING P a 7 PRESSURETESTING P 1 91 NONE P i 95 UNKNOWN P 9 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I 1,ESTIMATED OATE LAST USED(MO/YA) 2. ESTIMATED OUANTITY OF3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLOWS INERT MATERIAL? YES ::]NO :THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE 1S TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) j DATE LOCAL AGENCY USE ONLY E COUNTY M JURISDICTION! ALiENGT M } FACILITY IDM TANK ID M Fo7;�] CURRENT LOCAL LOCAL AOF.NCY FAgVM ID 6 APPROVED BY NAY! [ PHONE 0 WITH AREA CODE FERMRNYMBER PLRMRAPPROVAL'DATB PERMR,EXPIRATIONDATE r .y it CHECK!r PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT tf BY: FORM 8(6.29.66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',VNUESS A CURRENT FORM'A' HAS BEEN FILED