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STATE OF CALIFORN* WATER RESOURCES CONTO BOARD T FORM /8% ,.- UNDERGROUND STORAGE TANK PROGRAM � TANK TANK PERMIT APPLICATION INFORMATION all ;- COMPLETE A gEPAgAT!FORM WITH THE FOLLOWING INF MATION FOR EACH TANK. G MARK ONLY ❑ I NEW PERMIT ❑S RENEWAL PERMIT CHANOE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I c ONE TEEM 2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑0 TEMPORARY TANK CLOSURE ❑B TANK REMOVFD Y/ FACILFFY/EITE NAME WHERE TANK 16 INSTALLED: �-}Y c�i �.�s FARM TANK-YES ONO U FV 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY n FA A. OWNERBTANKK)• f ,1--- ( B. MANUFACTURED BY: J' C. YEAR INSULTED C7�L� O. TANK CAPACITY IN GALLONS: j i . �� c- � 11. TANK CqNnNTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AA),18 NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL [j 2 PETROLEUMC. ❑ I UNLEADED ❑ 2 LEADED DIESFL ❑S CHEMICAL PRODUCT ❑ B./OIL 1 PRODUCT ❑A GASAHOL ❑ 5 JET FUEL E] 8 AVIATION OAS ❑5 HAMA M" ❑SO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.E C A.S.0: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B,C.•D A TYPE OF WALLED []S MEWAUEDNTH EXTERIOR LNER ❑95 NDWN not Uh L(C--T- $YSTEM :saaEwwED ❑ 1 SECONDAMcarru rR 9s OTHER ,- 4-T✓p C , h f� SRFURON F]2 STAINLESS STEEL ❑1 FIBERGLASS [1] A MR CUD WIFIREIK9LAS5 REINFORCED PLASTIC 1.TANK MAIMATERIAL ❑S C I'M ❑e POLYVRM OAORIOE ❑ 7 ALIMIMM ❑8 1001IMETHANOLCOMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER _ C.RITERIOR E) I RtA1BERLNEO ❑2 AXYD LINING ❑S EPDXY L"NO L]1 PHENOUCLINING LINING ❑5 Mo u,," L j I OWNED ❑95 UNXNOYM ❑BLNRaMATERALCGMPATBIEWRH199WMEWNDLv ❑YES ❑NO ❑99 MR D.CORROSION ❑ I POLVETILENESRM ❑2 TAA OR ASPHALT 0 VIRAL WRAP _ FI BUD PLASTIC PROTECTNON ❑5 01THOMPROTEC1DN 0-§j"RW ❑95 UNKNOWN IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 19l1CIK9N A U 2 PRESSURE A U J GRAVITY A U 91 NONE A U 95 UNKNOWN A 1.CONSTRUCTION A # 1-w WALL--.? A U 2 DOUBLE WALLED A U S LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER AVL._) STEEL IRON A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NGNE C.MATERIAL A U e ALUMINUM A U e CONCRETE A U 7 STEEL CUD W/FRP A U 9 I"METHANOL COMPATIBLE FRP A U 0 GALVANIZED STEEL A U 95 UNKNOWN A U "OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR R FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P I IVISUAL CHECK 0 • 2 INVENTORY RECONCILIATION P •_S,VAD OSE WELLS P 8 / ELECTRONICMONDOR P 8 5 GROUND WATER MONITORING WFUS • •PRECIBKKI TESTING P • 1 PRESSUM IESTINO F,• 81 NONE'- p • 95 UNKNOWN p • 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESiWIATEO DATEUBT USED(MO/YR) F2. ESTIMATED QUANTITY OF O.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATEBML7 YES D NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'8 NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION SS AGENCY• FACILITY ID 1 TANK IO N E = = D I v_I l I c, i 1 Yc, 101 -0 CURRENT LOCAL ASENCY FACILITY M• APPROVED BY NAM! PHONE F WITH AREA CORE bt/ AK S G PeAMR NUAImER PERMIT APPROVAL DATE PlRMIT EXPIRATION DAT! CNlCR/ PlRMIT AMOUNT UR O!AYT. FEE CODE C! 0Y: 1, jf�ICl ronmSte2/.em THIS FORM MUST BE ACCOMPANIED BY A FACIIRY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASSEENRIlEO