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STATE OF CALIFORNIE WATER RESOURCES CONTROI ')ARD "'= FORM ': UNDERKGROUND STORAGE TANK PROC,"{�AM �' ' TANK TANK PERMIT APPLICATION INFORMATION ' s 3 C MPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z t CD MARK ONLY WEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 4bb A. OWNERS TANK ID# C)„ B. MANUFACTURED BY: U ov, v C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: 17-(O-o 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT —401L ❑ 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIAT19N GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN gr2 WASTE ❑ 7 METHANOL 2��99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# -I C.A.S.#: 2,0 3 5 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑98 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUM REINFORCED PLASTIC B.TANK MATERIAL CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP u'�^ BRONZE ❑10 GALVANIZEDSM ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBSERUNED El2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOLIC LINING LINING ❑5 GLASSLINING ❑ 6 UNLINED 8-95 UNKNOWN ❑ ISUNI14GMATERIALCOMPATIBLEWRH100EMETHANOL7 ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑/3 VINYL WRAP [74 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION E]91 91 NONE I�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 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C.MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AUj95 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. oa�Y P S 1VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS °IIS P PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY IDN TANK 10# 3fd o CURRENT LOCAL AGENCY FACILITY ID NNAME 1 1 PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DA PERMIT kPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B I6-29-eel THIS FORM MUST BE ACCOMPANIED oY A FACILITY/SREAPPUCATIOK FORM 'A',UNLESSRENT FORMAHAS BEEN FILED -— DATA PROCESSING COPY