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STATE,OF CALIFORNw WATER RESOURCES CONTI&BOARD op FORM 'R' UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION .' COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. Z c MARK ONLY —❑ 1 NEWPERMIT - ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P MANENTLY C NK 3 O ONE ITEM ?',❑ 2 INTERIM PERMIT_ ❑4 AMENDED PERMIT- ❑6 TEMPOR&W TANK CLOSURE TANK flEMOVE W FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TJANK•VES NO N I. TANK DESCRIPTION COMPLETE ALLITEMS•IFUNKNOWN-SOSPECIFY / Cp A. OWNERS TANK ID N I I B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(Ai),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 712 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL . ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑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 OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,A D A.TYPE OF ' ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH O TERIOfl LINER ❑95 UNKNOWN SYSTEM - ❑ 2 SINGLEWAUn ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑25TNNLESS STEEL r73 FIBERGLASS ❑ /STEEL CIAOWIFIBERGUSS REINFORCED FUSTIC B.TANK I : .:❑ 5 CONCRETE ❑ 6 POLYVWYLCHLOROE ❑ 7 ALUMINUM ❑ 5 100%METHANOL COMPATIBLE FRP MATERIAL, ❑ 9 BRONZE ❑ III GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER I RUBBERUNED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑4 PHEIIOWUNING C. INTERIOR LININGf7SS5 GUUNING 6 UNUNED ❑ 95 UNKNOWN ; ; � ❑ IS UNDID MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER F RROSION ❑ I POLYETKENEWRAP ❑ 2 TM OR ASPHALT ❑ 3 VIWLWIIAP ❑4 RBERGUSS REINFORCED PLASTIC OTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A V 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A V 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELIIRON A U 2 STAINLESSSTEEL 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 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 8 1 VISUAL CHECK P 8 2 INVENTOR/RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATEO DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY 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. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N '.JURISDICTION Y AGENCY N FACILITY ID M TANK ID Y mCQ� 663 i CURRENT LOCAL AGENCY FACILITY IDj.{�^ V / APPROVED BY NAME PHONE I WITH AREA CODE PERMITNUMBER , l/ o PERMIT APPROVAL DATE PER MIT EXPIRATION DATE 9� CHECKF PERMIT AYOUHT SURCHARGE AYT. FEE CODE 'ECEIPTI BY; �,49 le!FORM 8(6-29-B6) THIS FORM MUST BE ACCOMpANWY A FACILITY/SITE APPLICATION, FO RM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED