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STATE OF CALIFORNIA r WATER RESOURCES CONTROL RD FORMW: UNDERGRONDSTORAGETANK PG Mgo TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK 1CLOSURE N�EMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: a L .�I 4-V� FARM TANK-YES❑ NO � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C00 0 A. OWNERS TANK ID# I B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �U II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C. 1 UNLEADED 2 LEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. ❑ ❑ ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 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 CA.S.#: HAZARDOUS SUBSTANCE STORED&C A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER �oT95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE F—]6 POLYVINYL CHLORIDE F] 7 ALUMINUM E] 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ F-110 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER 9 BRONZE I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ` J D. CORROSION [:] YETHLENEWRAP 2 TARORASPHALT ❑ LINING F—] I ICIS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' El YES [:] NO OTHER 1 POL3VINYL 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 A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U q;UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH AV 91 NONE jCU 98 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLWINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 5L4 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ACU )5 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�-$�4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISIONTESTING P S 7 PRESSURETESTING P S 91 NONE P S S UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE LAST USED(MO/YR 2. ESTIMATED QUANTITY OF GALLONS 3.WAS TANK FILLED ESTIMATED DATE 7LASTED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E]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# 1 1 1j D7= EI I APPROVED M ONE# TH AREA CODE rCHECK# CAL AGENCY FACILITY ID# L BER PERMITA PROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: -- FORM B IB-29-B8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RENT FORM'A' HAS BEEN FILED ��