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STATE OF CALIFORI WATER RESOURCES CONT BOARD <br />FORM W: UNDERGROUND STORAGE TANK PROGRAa o <br />TANK PERMIT APPLICATION INFORMATION <br />TANK <br />COMPLETE A SEPARATE FORM WITH THE FALLOWING INFORMATION FOR EACH TANK. <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PER 5 CHANGE Of INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TANK REMOVED <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED:. y SfCJ it o / €7` <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY <br />R. OWNERS TANK ID # B. MANUFACTURED BY: <br />C. YEAR INSTALLED <br />D. TANK CAPACITY IN GALLONS: <br />FARM TANK - YES U NO <br />000 <br />IL TANK CONTENTS IF {A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. <br />A.E . 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED JW 2 LEADED ❑ 3 DIESEL <br />3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS <br />❑ 5 HAZARDOUS B© EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) <br />D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF CAS #: <br />HAZARDOUS SUBSTANCE STORED & C.A.S. # <br />— ..v r.r.uc+Tnl V^-Tlflwl &R—W nuc ivru nNl V IN RAY A- B. C. & D <br />III. <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE U 1 SUCTION A U 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 U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br />A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC} A U 4 FIBERGLASS PIPE A U 91 NONE <br />C. MATERIAL �A U S 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 P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br />P S 5 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE O8 95 UNKNOWN P S 99 OTHER <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1. ESTIMATEp RATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br />�/7 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES0 <br />THIS FOR HAS SEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE REST OF MY !(NOWLEDG IS TRUE AND CORRECT <br />APPLI lS NAM (PRINTED & IGNATURE). - j DATE <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />JURISDICTION # <br />AGENCY # <br />FACILITY ID # <br />TANK ID # l <br />CURRENT LOCAL AGENCY <br />FACILITY ID # <br />_ _ r <br />APPROVED BY N/IME <br />, — I— /+iI <br />PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />CHECK # I PERMIT AMOUNT <br />PERMIT APPROVAL DATE <br />SURCHARGE AMT <br />EXPIRATION DATE <br />FEE CODE I RECEIPT # <br />BY: <br />FORM s (6-29-88) THIS FORM MUST BE ACCOMPANOM A FACILITYISITE APPLICATION, FORM 'A', UNLESS AT%RENT FORMA' HAS BEEN FILED <br />DATA PROCESSING COPY <br />z <br />CA? <br />CA) <br />Ln <br />N <br />