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STATE OF CALIFOR`'A WATER RESOURCES CON,�X BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM ' e TANK OMTANK PERMIT APPLICATION INFORMATION a PLETE A SEPARATE FORM WITH THE FOLLOWING-!OpoimATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑0 AMENDED �PERMIT F-16 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED I� D FACILITY/SITE NAME WHERE TANK 18 INSTALLED: ��I N, //'J Cr/v1 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY FV A. OWNERS TANK IDN B. MANUFACTURED BY: u� C. YEAR INSTALLED p(�L D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑2 P EUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ER'4011. ❑ 1 P CT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A CA.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.8 D A TYPE OF ❑ 1 LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Lff2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER TANK SIEWIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS El/STEEL CUD W/FIBERGLASS REINFORCED PLASOC d MATERIAL ❑5 CONCPEiE ❑6 POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RIBBEALNIED ❑2 LINING 3 EPDXY LINING ❑A PHENOLICUNINO LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METFIAIK)L? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETI%£NE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑X RBERGLASSREINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION91 NOW ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRE A U 3 GRAVITY A A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A V 91 NONE C. MATERIAL A V 5ALUMINUM A U 6CONCRETE A U ISTEEL CUD W/FRP A U 6100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A �NOWN 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 E I VISUAL CHECK P B 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P B A ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P 1 6 PRECISION TESTING P B 7 PRESSURE TESTING P-•1'"9rVOq - P E 95 UNKNOWN P E 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAGALLONS TED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLF7ED WITH SUBSTANCE REMAINING IN INERT MATERIAL? Ej YES [_—] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N p / TANK IO N I CURRENT LOCAL AGENCY FACILITY ID N #DATMEPERMIT PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVEXPIRATION DAR CHECKI PERMIT AMOUNT rnRCHARGE AMT. P'-91"T0 BY: FORMB(629-ee) THIS FORM MUST BE ACCOMPANIED SYA FACR.RY/SITE APPLICATION, FORM 'A,,UNLESS A CURRENT FORMA' HASBEENFILED DATA PROCESSING CnPV