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I A) C Ur" CALIFUNNI ^ WATER RESOURCES CONTRF" BOARD FORM'S': UNDtrAGROUND STORAGE TANK PROGRAM TANK/ TANK PERMIT APPLICATION INFORMATION v COMPLETE A SEPARATE FORM WITH THE FOLLOWIN1INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 71MANENTLY CLOSE `P ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVEDroyf FACILITY/SITE NAME WHERE TANK IS INSTALLED: � �2 �� FARM TANK -YES 1. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p 8. MANUFACTURED BY: C. YEAR INSTALLED 7 y D TANK CAPACITY IN GALLONS Ove If. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ I UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ < GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW( C IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S. 4 C.A.S. p: TANM' f^ANcrol Irrinu ____._ ___ NO A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWAUED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER TANK I STEEUIRON [:]B. E]5 CONCRETE ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL C{ADW/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP ❑ 9 BR011ZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RIQBERUNFD ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOUCLINING LINING ❑ 5 GLSSUNING ❑ 6 UNLINED U 2 STAINLESS STEEL ❑ 95 UNKNOWN U 3 POLYVINYL CHLORIDE (PVC) A U ❑ IS UNING MATERIAL COMPATIBLE WITH 100% METHANOL' ❑ YES ❑ NO ❑ 99 OTHER rD.ORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR ORASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION nRrl l_ A o ., V. VI, A SYSTEM TYPE A U/ SUCTION A U 2 PRESSURE A U 3 GRAVITY APPROVED BY AUYE S. CONSTRUCTION A U 1 SINGLE WALLED A PHONE F WITH AREA CODE ArU 91 NONE A U 95 UNKNOWN A U 99 OTHER U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER C. MATERIAL 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 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 •�^^ .. • vv 1 wn a 10 1 CM CIRCLE P FOR PRIMARY. OR S FnR SFrnMnw.v w __..____.._....................�..,.,. ..c.caa limn STS I LM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER 1\ICnllu w�.w w. w •• �•••••^.. .� v.. 1l+nn rcn WIANCP/ 1 LT GLUSEL) 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 FARAA NAC GFFAI 64 , - — --- --- • -- • • •� •.�.. • ... nn n11U11LCUUC, 15 I HUL ANLL CL APPLICANT'S NAME (PRINTED 6 SIGNATURE) DATE lom^w 1 nn' i...... 7RECT COUNTY B JURISDICTION B AGENCY I FACILITY ID B TANK IDN V GURRENT LOCAL AGENCY FACILITY1 / % APPROVED BY AUYE �t A 1/T' / 'J PHONE F WITH AREA CODE PERMIT NUMBER CHECKS I PERMIT FORM B (6-29-88) THIS FORM PERMIT PERMIT AMT. I FEE CODE 4ECEIPTI A FACILITY/SITE APPLICATION, FOR M 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY z •O