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STATE OF CALIFORNIA* WATER RESOURCES CONTROL&ARD <br /> FORMW: UNDERGROUND STORAGE TANK PROGIIAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY r_� 1 NEW PERMIT 1:1 3 RENEWAL PERMIT [::] 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM El 2 INTERIM PERMIT F ] 4 AMENDED PERMIT 17 6 TEMPORARY TANK CLOSURE V6 TANK REMOVED jw <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 161Y 10, ZN=Zi;42,Q FARM TANK-YES[::] NO <br /> 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A, OWNERS TANK ID h 6, MANUFACTURED BY: <br /> C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: 0 Q <br /> II. TANK 2ONTENTS IF(A.11),IS MARKED,COMPLETE ITEM C.If(A.11),IS NOT MARKED,COMPLETE ITEM D. cn <br /> A. Rrl MOTOR VEHICLE FUEL F-1 2 PETROLEUM B C [::] 1 UNLEADED P�1'2 LEADED D 3 DIESEL <br /> El 3 CHEMICAL PRODUCT F-] 4 OIL �1/1 PRODUCT 1:1 4 GASAHCL E:] 5 JET FUEL [:] 6 AVIATION GAS <br /> [:] 5 HAZARDOUS [:] 80 EMPTY [:] 95 UNKNOWN 2 WASTE 7 METHANOL [:] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.9 CA.&H: <br /> xIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&1) <br /> A.TYPE OF F-] 1 DOUBLEWALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM qr_5'l4NGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> E2o'l'STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM a i co%METHANOL COMPATIBLE FRP <br /> MATERIAL 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> F—I 1 RUB8ER LINED F-] 2 ALKYO LINING F_� 3 EPDXY LINING E] 4 PHENOLIC LINING <br /> C. INTERIOR I <br /> LINING 5 GLASS L;'NtNG 6 UNLINED F4.eUNKNOWN <br /> ISUNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [�j NO 99 OTHER <br /> D. CORROSION F-1 1 PouETHLENE WRAP 2 TAR OR ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION E] 91 NONE Z450OUNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A nU95 UNKNOWN A U 99 OTHER <br /> A U I STEFL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 AL UMINUM A U 6 CONCRETE A U 7 STEEL CLA0W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A to 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> #)kll P : I VISUAL,CHECK I P IS 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 6 PRECIS ON TEST NG P S 7 PRESSURE TESTING 0 S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> !'1 11 11''I D D'i E 01 1:1 USED(VO/YR) 2. FSTI ATED UANTrrY OF 3 WAS TANK FILLED WITH <br /> SUB TANCE REMAINING IN GALLONS INERT MATERIAL? YL' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MYKNOWLEDGE,IS TRUEAND CORRECT. <br /> IAPPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> ECOUNTY# JURISDICTION# AGENI FACILITY ID# TANKID# <br /> [al I I I I El I I I 10 11111 k= rol nl (01 P� <br /> CURRENT LOCAL AGE14CY FACILITY ID APPROVED BY NAlt� PHONE#WITH AREA CODE <br /> C NTY <br /> OU <br /> C R?LOCAL <br /> U EINT <br /> PERMIT NUMBER PERMIT APPROVAL DA�E PERMIT EXPIRATION DATE <br /> CHECK# PERMIT A OUNT SURCHARGE AMT. FEE CODE RECEIPT <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED b7-A FACILITYISITE APPLICATION, FORM 'A',UNI ESS A CVWENT FORMW HASBEENFILED <br /> DATA PROCESSING COPY <br />