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STATE BOF CALIFORNIP WATER RESOURCES CONTRO' ZOARD FORM ` ': UNDERGROUND STORAGE TANK PROMAM TANK TANK PERMIT APPLICATION INFORMATION m` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.MARK , ONE ITEM ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT �6 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: rFARM TANK-YES❑ NO 4FCI' Z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY to A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 7�1 �aa 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑1 UNLEADED ❑2 LEADED ❑3 DIESEL W ❑3 CHEMICAL PRODUCT �OIL �-y �J ' PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS i ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /wV^' HAZARDOUS SUBSTANCE STORED&CAS.# Z4 C.A.S.#: O� All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.IL D A TYPE OF ❑ 1 DOUBLE WALI ED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM laf SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER Ea-1 ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK ERIAL ❑5 CONCRETE ❑8 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8190%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED ME ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING �-y LINING ❑ ® 5 GlASSUNING 6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP '®'(TAR OR ASPHALT 0 3 WNYLWRAP ❑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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL AQ95 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. O P 8 1 VISUAL CHECK O 8 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTING P 3 7 PRESSURETESTING P 8 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/VRI 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? DYES �NO ' GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY# FACILITY IDX TANK ID# ! CTO / 3 lololoFsT CURRENT L�D OENCY FACILITY IDX APPROVED BT'!U'EPNONE X WITH AREA CODE PERMIT NUMBER LS PERMIT APPROVAL DATE fl4�iPERMIT EKPIRA DkfE CHECK# PERMIT AMOUNT SURCHARGE AMT. 717ECODE RECEIPT# BY: FORMB(3-7-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HASBEENFILEO DATA PROCESSING COPY