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TATE OF CALIFORhft WATER RESOURCESCONT10OARD 'P FORM W: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION „ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVtq I FACILITY/SITE NAME WHERE TANK IS INSTALLED ] 3a r FARM TANK-YES❑ NO Z I. TANK DESCRIPTI COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID S ('f/]/L B. MANUFACTURED BY' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q(� W cy 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL PETROLEUMB. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL 9 F-] 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT I ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN [:] 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME (� ' HAZARDOUS SUBSTANCE STORED 8 C A.S.# '% C.A.S.M XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANKIq ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE IDI7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEELUNKNOWN ❑99 OTHER ❑ I RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHE CURING C. INTERIO LINING ❑5 GLASSUNING ❑6 UNLINED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL ❑YES 0 ❑99 OTHER D. CORROSIO IS ❑ 1 POLYETHLENE WRAP ❑2 TAO OR ASPHALT [:] 3 VI WRAP [:]4 FIBERGLASS REINFORCED PLASTIC PROTECTI 5 CATHODIC PROTECTION ❑91 NONE 5 UNKNOWN ❑99 OTHER IV. PIPING INFO MATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE(IV A U 1 SUCTION Afi;h PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTI A U 1 SINGLE WALLEO A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIALa1 A U 5 ALUMINUM AU 6 CONCRETE A U 7 STEEL CI-ADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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. � S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS R,yl P 8 6 PRECISION TESTING P S 7 PRESSURETESTING (I)s 91 NONE 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE LAST U ED(MQ/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH z'[ SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO T THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY //'' COUNTY# JURISDICTION# AGENCY# iiry FACILITY ID# 7- TANK ID# NT LOCAL AGENCY FA ILITY ID k OVED BY NAME PHONE# ITH AREA CODE T A(,3 Z 6-90 /s MIT NUMBER P IT`APPROV ATE SAINT EXPIRATM DATE CHECK* PERMIT AMOUNT SURCHARGE ANT. ,/•// FEE CODE RECEIPT* BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORNWUNLIRFACURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY