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f STATE OP CALIFORN1 WATER.RESOURCES CONTRO�OARD : • UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATIONo TAN K Y COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. 9";} i ❑1 NEW 3 RENEWAL PERMIT'PERMIIT" ❑ 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL • ". � ONE ITEM" �„ a'"".❑,2 INTERIM PERMIT. ❑4 AMENDED PERMIT. ❑8 TEMPORARY TANK CLOSURE ❑$TANK REMOVED Q FACILITY/SITE-NAME WHERE TANK IS INSTALLED: FARM TANK-YES HO ❑ 4•/N`I L'TANK DESCRIPTION COMPLETE ALL ITEMB-IF UNKNOWN—SO SPECIFY A.""OWNERS TANK IDS B. MANUFACTURED BY: e4% i C.YEAR.INSTA-L.6. D. TANK CAPACITY IN GALLONS: w 11.`TANK96NtENTS IF(A.1),IS MARKED,COMPLETE ITEM Q4F(A.9-11(s S NOT MARKED,COMPLETE ITEM D. ;_. A 1 MOTOR VEHICLE FUEL 2 PETROLEUM B: C.j'❑ 1 UNLEADED ❑2 LEADED DIESEL it 4 GASAHOL 5 JET FUEL 6 AVIATION GAS 3 CHEIAICALPRODUCT ❑4 OIL 1 PRODUCT u❑ ❑ ❑ ❑"S.HAZARDOUS [3 88 EMPTY C]95 UNKNOWN [D 2 WASTE `❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF. HAZARDOUS SUBSTANCE STORED d C.A.S.N. C.A.S.N: NI. TANWCONSTRUCTION MARK ONE ITEM ONLY IN Box A,S.C.&D L TYPE of ❑-1 DOUBLE WAUS ❑3 SINGLE WALLED WITH D(TERIOR LIVER E3,95 uwmm SYSTEM.. []2 SINGLE WALL® . ❑4 MCONDARYCONTAINMEHT "„ E]'99 OTHER 1 UEEUMON ❑2 STAINLESS STEEL. E:]'3 RBERGLMS ❑/STEEL OAA WIFIBEAGLASSXWORCI:D PLASTIC ' B`TANK "❑S WNWR ❑B POLYVINYL 010FUM ❑;7 AUANNUM ❑B 100%UEMANOL COMPATIBLE FRP MATERIAL,.', ❑9 BRONZE ❑ T9 GALVANIZ6DSTEEL ❑95 UNKNOWN ❑99 OTHER Cr INTERIOR ❑"I RUBBERumm ElU(YD 2 ALIMNO El EP011lf UMNG ❑4 f4i XOUC UMNG LINING El 50LAMLIN1NIi ❑8 MUNED ❑95 UNKNOWN ❑Ii6MNG VATW AL0WATIB>.E WI IW%iWKq OLr E]yes ❑NO ❑99 OTHEII d.CORR(ISION . ❑I YETIIIJ wRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ RSERGLASS REINFORCED PLASTIC PROTECTION ❑"5 CATFIGDICPROTECTION ❑91 NOW es UNKNOWN ❑90 OTHER W. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE s- A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY IS A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A V 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE Q MATERIAL "A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD,W/FRPA "U 8 1DOMi 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 $"FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P i I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P i o ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISKIN TESTWG P • 7 PRESSURE TESTING P i 91 NONE P 6 95 UNKNOWN P 6 "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 INERT MATERIAL? [:]YES ❑ NO GALLON, THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJYR!.AND TO THE BEST OF MY KNOWLEDOE,IS TRUE AND CORRECT. AI'PLIGANTS NAME(PRINTED A SIGNATURE) BATE LOCAL AGENCY USE ONLY COUNTY# ' '-JURISDICTION* AGENCY# I FACILITY ID# TANK ID# t d To -1 CURRENT LOCAL AGENCY iA ID• /^/ APPROVED BYNAME ';' PHONE WITH AREA COLE PERMIT NYMBER. :'" PERMIT APPROVAL'DATE PERMIT,EXPIRATION DATE. E; _ /0 CHECK II PERMIT_AMOUNT SURCHARGE AMT, FEE COOS RECEIPT M BY- • FORM s{e 29 66} THIS FORA MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'XUNLESS A CURRENT FORMA' HAS BEEN FILED