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bl Al t OF CALIFORNIA WATER RESOURCES CONTRA'- BOARD FORM'S': UNDLnIGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION �COMPLFTF A SFDADAre c '--... '-•- • "��•'•••••� Inr VN I -UH EAC" TANK. MARK ONLY ❑1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGEOF INFORMATION ONE ITEM 7 P ANENTLY E]2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: /FARM TANK -YEWil�S EDN rANKDESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN—SO SPECIFY C I'll I III. TANK CONSTRUCTION MARK ONE ITEM ONLY w wnV • w A TYPE OF A. OWNERS TANK ID # ❑ 3 SINGLE WALLED WITH EXTERIOR LINER B. MANUFACTURED BY: 74 SYSTEM 2 SI WALLED C. YEAR INSTALL .(� D. TANK CAPACITY IN GALLONS: EP"1 STEEL/IRON II. TANK C TENTS IF (A7), IS MARKED, COMPLETE ITEM C. IF (a1), I OT MARKED, COMPLETE ITEM D. ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC A MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLE:0:Eol:g LEADED DIESEL3 A A A CHEMICAL PRODUCT ❑4 OIL I PRODUCT 4 GASA JET FUEL ❑ 6 AVIATION GAS❑ ❑ I RIBBER LINED 5 HAZARDOUS 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METH OTHER (DESCRIBE IN ITEM D, BELOW) ❑ 6 UNLINED D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%MMMOL? ❑ YES ❑ NO HAZARDOUS SUBSTANCE STORED 8 C.A.S. R D• CORROSION C.A.S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY w wnV • w A TYPE OF ❑ 1 ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SI WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK EP"1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP A A A ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RIBBER LINED ❑ 2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED FEE CODE ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%MMMOL? ❑ YES ❑ NO ❑ 99 OTHER D• CORROSION ❑ I POLYETHLfNE WRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION rimy. c a •, ....._____..__ V. EA A SYSTEM TYPE B. CONSTRUCTION A A U U 1 SUCTION 1 SINGLE WALLED A A U U 2 PRESSURE 2 DOUBLE WALLED A A U U 3 GRAVITY ArU 91 NONE 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U 95 UNKNOWN A U 99 OTHER A U 99 OTHER C. MATERIAL A A A U U U 1 STEEL/IRON A 5 ALUMINUM A 9 GALVANIZED STEEL A U U U 2 STAINLESSSTEEL 6 CONCRETE 95 UNKNOWN A A A U U U 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL CLAD W/FRP A U 99 OTHER 4 FIBERGLASS PIPE A U 91 NONE B 100% METHANOL COMPATIBLE FRP •�...• vc . ca. I I V IY J T J 1 CAR CIRCLE P FOR PRIMARY, OR S FOR SECONDARY A PRIMARY I FAr nc.cn.,.... e....�.. ... _-_.. �-. �........ v • a. c,w IIwIJ I OC GINI:LGD. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S %OTHER u.1w .. _-___-- ••• ....... I IVIY vIY I n1Yn vEnBRAPICIV 1 LT GLUSED IN PLACF 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN DALLONS INERT MATERIAL? ❑ YES ❑ NO THIS FnPU MAC - - - --- -- ••• -- • �-- �•••��. L . r Ur rcnJUHT, AINU IU I Fit HEST OF MY KNOWLEDGE, IS TRUE AND CI APPLICANTS NAME (PRINTED 8 SIGNATURE) DATE 3RECT. COUNTY Y JURISDICTION R AGENCY R FACILITY ID N -L7 TANK ID N CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE •WITH MEA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE R'CEIPTI BY.. FORM B (6-29-BB)THIS FORM MUST BE ACCOMPANIElT6'IA FACILITY/SITE APPLICATION. FORM 'A'. ILMI FSC A M-- — 'A. . ..__.. _.. UAIA PROCESSING COPY