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'{ .-_ .e.,v..•..*,._.-4.;-..v}5, .-.,.mss. R•, .,__ , Qb^WO w STATE OF CALIFORN�" WATER RESOURCES CONTR; ARD UND�ROUND STORAGE TANK PRAM FORMW:. TANK TANK'PERMIT APPLICATION INFORMATION op,r COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 ORMATION FOR EACH TANK. -= MARK ONLY F-11 NEW PERMIT F-13 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL0r5ED T I ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: J FARM TANK-YES❑44 NO Q • I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY y A. OWNERS TANK ID# B. MANUFACTURED BY: 1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: i ba j II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PROD T ❑4 GASAHOL ❑ 5 SET FUEL ❑ 6 AVIATION GAS I ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) I. D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OFC.A.S.#: uI�� HAZARDOUS SUBSTANCE STORED&C.A.S.# &a III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D A.TYPE OF W'25�!NGILE 1BLE WALLED F—] 3 SIN&EWALLED WITH EXFERIORLINER ❑95 UNKNOWN SYSTEM WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 6 10096 METHANOL COMPATIBLE FRP c MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHE LIC LINING i C.INTERIOR ❑ LINING 5 GLASS LINING F-16 UNLINED UNKNOWN � ❑ ISLININGMATERIAL COMPATIBLE WITH}00%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VI P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 5 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 LINFD TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON 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 6 100%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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION ' P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑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 10 TANK ID# L- Eo:: D CURRENT LOCAL AG CY FACILITY 10 0 APPROVED YNAM PHONE N WITH AREA CODE { Q 7 1-1 PERMIT N MBR PERMIT APPROVAL DATE RMIT EXPIRATION DATE CHECK N PERMIT AMOUNT —SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLES6A`b3rRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY