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STATE OPCALIFQRN10' WATER RESOURCES CONTRAOARD ` = FORM 'E'. UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION rx TANK,-:,'NCOMPLETE A SEPARATE FORM WITH THE:FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY. 1:.. ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F__17 PERMANENTLY CLOSED T K V ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE E30 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 441 FARM TAWK-YES NO C ❑ FV 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN--50 SPECIFY j�j S'S E/7 A. OWNERS TANK 10 N B. MANUFACTURED BY: C. YEAR INSTALLED ,'1� D. TANK CAPACITY IN GALLONS: �� a II. TANK CONTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM EI. C ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ i PRODUCT E] 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS [D❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A S H- 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER [] 95 UNKNOWN SYSTEM. ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON E]2 5TAINLESS STEEL F73 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLOFIDE ❑ 1 ALUMINUM ❑ B IW%METHANOL COMPATIBLE FRP MATERUIL., ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS UNING ❑6 UNUNED ❑95 UNKNOWN ❑ IS bNING MATERIAL COMPATIBLE WITH I OD%METHANOL? ❑YES ❑NO ❑99 OTHER D,CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 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 U 3 GRAVITY A U 9l 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 STEELARON A U 2 STAINLFSS STEEL A U 3 POLYVINYL CHLORIDE)PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U B CONCAETE A U 7 STEEL CLAD W/FRP A U H 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. LP B I VISUAL CHECK P B 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P 1 8 PRECISION TESTING F i 7 PRESSURE TESTING P 6 91 NONE P 6 95 UNKNOWN P 6 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 INEHT MATERIAL? ❑ YES NO TH1S FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST Of MY KNOWLEDGE, IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 41 ' JURISDICTION 1 AGENCY M FACILITY ID Y , TANK ID N TTI CURRENT LOCAL AGENCY FACILITY ID N / APPROVED BY NAME PHONE N WITH AREA CODE u 6 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK! PERMIT AMOUNT IWRCHARGIAIAT, FEE CODE IPT N BY: p�;` FORM B{a-29--a) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED