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.STATE OF ,CALIFORNl,., WATER RESOURCESCONTRL_ BOARD :.;. <br /> 'UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> •—`COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z <br /> 10 <br /> MARK ONLY i�.-Q 1 NEW PERMIT . D RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLYCLO <br /> ONE ITEM 2 INTERIM PERMIT 1AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �6 TANK REMOVED a ) <br /> FACILITYISITE NAME WHERE TANK 18 INSTALLED: S FARM. <br /> •YES HO I FV <br /> 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-60SPECIFY 9s <br /> Oa <br /> A OWNERS TANK 10 N S L r - B. MANUFACTURED BY: C� <br /> C. YEAR INSTALLED 9�(' D. TANK CAPACITY IN GALLONS: )e:�) <br /> 11. TANK CONTENTS IF(A.1 9 MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. <br /> A 1 MOTORVEHICLE FUEL '„i 2 PETROLEUM B. C. [] I UNLEADED El 2 LEA 7 DIESEL <br /> ❑3 CHEMICAL PRODUCT 1 OIL ,ILJT/, I/pgOpUCT 1 GA LAHOL 5 FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS W EMPTY 95 UNKNOWN 2 WASTE I METHANOL 99 OTHER IGEBGRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&CAS.N k _ AQ f#u`II 4�, C I C.A.S.N: f <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B•C,i D <br /> ATYPE OF' ❑ 1 DOUBLE WALLED 0SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑ 2 SINGLE WALLED 1 SECONDARY CONTAINMENT 99 OTHER <br /> .❑ 1 STEEURON 2 STAINLESS STEEL E] 7 FIBERGLASS 1 STEEL CLAD W/FIBERCJASS REINFORCED PUSTIC <br /> 6.TANK.. ;7 5 CONCRETE 6 POLYVIWL0 LORDE 7 ALUMINUM 8 100%MEDNNOL COMPATIBLE FRP <br /> }r,.•I Q 9 BRONZE Q 10 GALVANIZED STEEL %UNKNOWN 99 OTHER <br /> 1.. •.• a I RUBBER LINED 2 ALKYD LINING 2 EPDXY LINING /PHENOLIC LINING <br /> C.INTERIOR. :; <br /> LININD,, ;•'•..�❑ 5 GLASS LINING 6 UNLINED %UNKNOWN <br /> . '❑ IS LINING MATERIAL COMPATIBLE WITH 100%MERW40L? YES ❑ NO 99 OTHER <br /> D.CORROSION ❑ 1.POLYERILENEWRAP E] 2 TM OR ASPHALT ❑ 2 VWYLWRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION g UT110DIC pgOTE gl NONE %UNKNOW?! 99 OTHER <br /> IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEMTYPE A U I SUCTION A U 2 PRESSURE A U B GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHEfl <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 7 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STLEWIRON A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL 'A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD WAFRP A U B 10091 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 0 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P-9 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P O 95 UNKNOWN P 9 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF7.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? YES E] NO <br /> GALLON/ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> T7 <br /> NAME(POINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# ' JURISDICTION 8 AGENCY 8 FACILITY ID Y TANK 10 e <br /> CURRENT LOCAL AGENCYG4/FACILRY 10 1 APPROVED BY NAY! PHONE I WITH AREA CODE <br /> �� .lr <br /> PERMIT NUYBEA PERMITAPPROVALDATE PERMIT EXPIRATION DATE n <br /> CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CDOE ...� ECLIPT N <br /> BY; <br /> \ / W <br /> FORM B(a•29.88) THIS FORM MUST BE ACCOMPANIED RYA FACII I 'CrTr ION le'1TIA, 17n n l f 'A' <br />