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STATE OF CALIFORNI WATER RESOURCES CONTROSPARD FORM W: UNDEROUND STORAGE TANK PRO RAM m' TANK TANK PERMIT APPLICATION INFORMATION. COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. F-11 NEW PERMIT F-13 RENEWAL PERMIT FEr 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: . (� r'JF} t FARM TANK-YES❑ NO A cil I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: W C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �/� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 P7ROLEU B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 O 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑SO 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE,IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / C.A.S.W �1/ //` HAZARDOUS SUBSTANCE STORED&C.A.S.# n•� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF ❑ ' DOE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM (SING UID ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER EAISTEEL/IRON ❑2 STAINLESS STEEL ❑ 3 PBERGIASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBERUNED ❑2 AptINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING UNUNED ❑ 95 UNKNOWN LINING ❑ ISUNING MATERIAL COMPATIBLE WITH 100% ANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHIENE WRAP 6TAR 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 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A 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 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A 0 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISIONTESTING P 8 7 PRESSURE TESTING - P S 91 NONE P S 95 UNKNOWN P S 99 OTHER 1 VI. INFORMATION ON TANK ��APERMANENTLY CLOSED IN PLACE TANK FILLED WITH 1. ESTIMATED DATE LAS TUSED( /V 2. ESTIMATED QUANTITY OF 3.WAS �j/// SUBSTANCE REMAINING IN INERT MATERIAL? GALLONS ❑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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY k FACILITY ID# TANK ID# Ea= od0 CURRENT LOCAL pOE CY FACILITY IDM APPROVED BY NAM PHONE M WITH AREA CODE PERMIT NUMBED PERMIT APPROVAL DATE oERM� PIRATION E CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: lift I FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED a,A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CKIRENT FORMA' HAS BEEN FILED S DATA PROCESSING COPY