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STATE OF CALIFORN14 WATER RESOURCES CONTRC&ARD FORM VUNDE GROUND STORAGE TANK PROINFRAM � 6 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑�T-�/7 PERMANENTLY CLOSED'TANK I O ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE NJ 8 TANK REMOVED oq FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO rD (JI I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# y B. MANUFACTURED BY: CJ1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ov II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. A 1 M070R VEHICLE FUEL [--12 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL j PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRI E IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑�1 DOUBLE WALLED [:]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN B�I� SYSTEM SINGLEWAUED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ©1 STEBUIRON ❑2 STAINLESS STEEL E]3 FIBERGLASS E]4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM L]8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD 3 EPDXY LINING 4 PHENOLIC LINING D LINING ❑ LINING [:] 5 GLASS LINING 216 UNLINED ❑95 UNKNOWN ` F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO �99 OTHER ! D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAA OR ASPHALT ❑3 VI WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION U 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 i STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER V. LEAK DETECTIO SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. jot P 1 VISUAL CHECK 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �'./ r P PRECISION TESTING S 7 PRESSURE TESTING 6 91 NONE P 8 95 UNKNOWN P B gg OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED 5L NTITY OF &WAS TAN FILLED WITH SUBSTA C ING IN GALLONS T IN T IAL? ❑YES ❑ NO THIS FORM'HASPEA COMPLETED UNDER PENALTY OF RJURY,AND TO THE BEST OF MY KNOWLE GE IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# I JURISDICTIONN## AGENCY# FACILITY ID# TANK ID# oa D CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA PHONE#WITH AREA CODE P/47A-9-- PERMIT U l NUMBER PERMIT APPROVAL DATE PERMIT XPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESS A CUR NT FORMA' HAS BEEN FILED DATA PROCESSING COPY