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STATE OF CALIFORNIA' WATER RESOURCES CONTROP —OARD �. FORMW:: UNDEftROUND STORAGE TANK PRO rMAM TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED FACI'LITYISITE NAME WHERE TANK IS INSTALLED: 50 FARM TANK-YES❑ N0 1. TANK DESCRIPTION COMPLETE ALL ITEMS-If UNKNOWN SO SPECIFY A. OWNERS TANK ID# r B. MANUFACTURED BY -::I► C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ i UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL I PRODUCT ❑ 4 GASAHCL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE 1 ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN STEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA S.# C A_5.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,6 D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [;1-2SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FI8ERGLASSREINFORCED PLASTIC B.TANK 715 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ A I00%METHANOL COMPATIBLE FRP MATERIAL 1-1 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER G. INTERIOR F-11 RUBBER LINED F--] 2 ALKYD LINING F—] 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ©LINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑-91'iGUNE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, 'U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 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 AU 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C, MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U B 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. L 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS -1i PS 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P $ 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 INERT MATERIAL? 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I 1 11 El I I I I I / 0 ED1 () 16 1�f CURRE14T LOCAL AGENCY FACILITY ID# APPR ED BY NAME PHONE R WITH AREA CODE ZB PERMIT NUMBER PERMIT APPROVAL DATC PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM 8;6-29-ee) THIS FORM MUST BE ACCOMPANIED Y A FACILITY151TE APPLICATION, FORM `A",UNLESS A TRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY