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STATE OF CALIFORNk..� WATER RESOURCES CONTRC OARD FORM W: UNDERGROUND STORAGE TANK PR000 RAM TANK TANK PERMIT APPLICATION INFORMATION Son,. W M4•Lt ft A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT lie5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D I FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN—SO SPFCIFY A. OWNERS TANK ID# �2— C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS B. MANUFACTURED BY: ❑ 2 WASTE C. YEAR INSTALLED D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: D. TANK CAPACITY IN GALLONS' �Q OQf II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.11. IS NOT MARKED_ COMPLETE ITEM n A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL B. �pRODUCT C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. # C.A.S. #: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, S D A TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER A U 95 UNKNOWN ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 1DD%METHANOL COMPATIBLE FRP A U 95 UNKNOWN ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F—]3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED A ❑ 95 UNKNOWN A ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR 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 U 1 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 PERMIT AMOUNT A U 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 W/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. P S 1 VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 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 HENIN(TYY�# SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES E]NO CURRENT LOCAL AGENCY FACILITY ID # GALLONS APPROVED BY NAME 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 JURISDICTION # AGENCY # FACILITY ID # TANK ID # HENIN(TYY�# CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEECODE RECEIPT# BY: FUHM B (E n w) Inti FUNM II I I t ACCUMPANIEU BY A FACILITY/SITE APPLICATION, FUHM W, UNLESS ACURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 10 cn N CION cn