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STATE OF CALIFORIY' ' WATER RESOURCES CONTE 30ARD FORM W: UNDVMGROUND STORAGE TANK PRZSGRAM TANK TANK PERMIT APPLICATION INFORMATION . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED OZ FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN—%0 SPECIFY IC A. OWNERS TANK ID It 021- B. MANUFACTURED BV: /� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: `1 DO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D 0 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM W[ WRAO C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESEL A ❑3 CHEMICAL PRODUCT ❑ 4 OIL DUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑M EMPTY 95 UNKNOWN TE ❑7 METHANOL ❑99 OTHER(DE E IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# AJIA C.A.S.#: 411. TANK CONSTRUCTION MARK ONE I EM ONLY IN BOX A,B,C,A D A. TYPE OF t UBLEWALLED ❑ 3 SINGLE WAILED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 PDLYVINYLCHLORIDE ❑7 WMINUM ❑8188%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 18 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOUCUNING C. INTERIOR F-1 LINING 5 GLASS LINING �UNllNED ❑95 UNKNOWN ❑BUNING MATERALCOMPATIBLEWITH 1D0%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE- ! U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 FISERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. L✓ '• P VISUAL CHECK /�_P/� 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING F S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOS D IN PLACE 1. ESTIMAT D/LTE LAST USED IMO/YR) 2 ESTIMATE A TIN OF 3 WAS T N F,1 ED WITH A SUB A E MING IN fl M 1 L? ❑YES ❑ NO GALLONS THIS F RM HAS BEEN COMPLETED UNDEF PENALTY OF AERJURY,AND TO THE BEST OF MY KNOWLED E,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY# FACILITY IDN TANK ID# CURRENT LOCAL AGENCY FACILITY IDX APP VE SY NA PHONE X WITH AREA CODE ti6Tl PERMIT NUMBER PE R PPROYAL D PERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT -SURC AMT. FEE CODE ECEIPT# BY: FORMB(3-7-8e) THIS FORM MUST BE ACCOMPANIE A FACILRY/SRE APPLICATION, FORM'A',UNLESS A ENT FORMA HASBEENFILED -DATA PROCESSING COPY