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STATE OF CALIFORN G O WATER RESOURCES CONTR OARD q°"•u�`:>N£ aROUND STORAGE TANK PR FORMB . UNDER RAM . TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -" z fo to MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 P RMANENTLY CLOSED TANK ONE ITEM [:] 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED G FACILITY/SITE NAME WHERE TANK IS INSTALLED: o () t&(?�57 L, FARM TANK-YES❑ NO W to I, TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C" A. OWNERS TANK ID# B, MANUFACTURED BY: 44.- C. YEAR INSTALLED (.4t/ D. TANK CAPACITY IN GALLONS: 7 j Il. TANK CONTENTS IF(A•1).IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTCR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED ❑ 2 LEADED ® 3 DIESEL ❑3 CHEMICAL PRODUCT [jKOIL ' PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL Ej4�OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / (�✓ HAZARDOUS SUBSTANCE STORED&C.A.S.N /Ir tea /I.G a/ / C.A.S.#: I Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,s D A.TYPE OF ❑ 1 RUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED [:]4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 5TEELfIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASSREINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNUNED alelUNKNOWN LINING @S LINING MATERIAL COMPATIBLE WITH lOn METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASSREINFORCEDPLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE �5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A(D 95 UNKNOWN A U 99 OTHER 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AID 96 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. P S 1 VISUALGHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADDSE WELLS P $ 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P S B PRECISIONTESTING P 8 7 PRESSIRETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPL6CANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY ENUMBER RISDICTION# AGENCY# FACILITY ID# TANK ID# I LLFI oL9 � 60 ILITY ID# --l-APPROVED BY NAME PHONE#WITH AREA CODE t F V iJ� F fr PER APPROVAL DATE P' RMiT EXPIRATION DATE T AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 'll FORM R(6-29-88) THIS FORM MUST BE ACCOMPANIE I A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY