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STATE OF CALIFORNIA ORNI WATER RESOURCES CONTROL ARD FORM W: UNDERGROUND STORAGE TANK PROGRAM o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT E? -5' --CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED 3 ,�� p� �'C (� FARM TANK - YES NO ❑ uv e1rl�/'�nInTIA\1 . ,rcue _ ¢ "-vmnWM — SO SPECIFY #4111111%VGJ\+171r Iv�� a.vmrcc, c n - .. _- SPECIFY A. OWNERS TANK ID # p �TANK FACTURED BY: (,.�(c C. YEAR INSTALLED ` CAPACITY IN GALLONS: S®(7 A� II. TANK CM MARKED COMPLETE ITEM C IF (A.1) IS NOT MARKED, COMPLETE ITEM D. I GI IF (A.1), B. C. ❑ 1 UNLEADED ❑ 2 LEADEDDIESEL A. [Z 1 MOTOR VEHICLE FUEL ❑1. 2 PETROLEUM V2S;LLE WALLED ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ©1 STEEL/IRON ❑ 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 C.A.S. #: HAZARDOUS SUBSTANCE STORED & C.A.S. # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D E WALLED A. TYPE OF ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM V2S;LLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER U 2 PRESSURE ©1 STEEL/IRON ❑ 2 STAINLESS STEEL F-13 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER A A=UNKNOWN ❑ 1 RUBBER LINED F-12 ALKYD LINING F -]n 3 EPDXY LINING 4EWNOUC LINING C. INTERIOR LINING ❑5 GLASS LINING F-1✓ 6 UNLINED U 9 GALVANIZED STEEL AA 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3N RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ER45 UNKNOWN ❑ 99 OTHER IV. rw,•.0 �•I/1u none loin 11 ICI UNDERGROUND BOTH IF APPLICABLE 1'IYIIVIoI Iryrvrsmfa I IVIS ldlSl�LC r Ir /lovvl w.vv.✓, .+ ��••-�• •--..----BOTH V I CAI[ nWTFf`TInhl SYSTFM (;IRC;I F P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 N NE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE T- 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS THIS FC non AOI rrcn UNDER PENALTY OF PFR.IIIIRY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. vvi ono o�uv vvvn "., ._ .. _ . -- -- - APPLICANT'S NAME (PRINTED 8, SIGNATURE) DATE LUUAL AIar-r4toT Vx ONLY SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NO A U 95 UNKNOW A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER C. MATERIAL A A U 1 STEEL/IRON U 5 ALUMINUM A A=UNKNOWN U 2 STAINLESS STEEL A A U U 3 POLYVINYL CHLORIDE (PVC) A U 7 STEEL CLAD W/FRP A U 4 FIBERGLASS PIPE A U 91 NONE 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AA U 99 OTHER V I CAI[ nWTFf`TInhl SYSTFM (;IRC;I F P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 N NE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE T- 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑ YES ❑ NO GALLONS THIS FC non AOI rrcn UNDER PENALTY OF PFR.IIIIRY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. vvi ono o�uv vvvn "., ._ .. _ . -- -- - APPLICANT'S NAME (PRINTED 8, SIGNATURE) DATE LUUAL AIar-r4toT Vx ONLY COUNTY # JURISDICTION # AGENCY # FACILITYID# TANK ID S# CUR RENYLOCAL AGENCY FACILITY ID # APPROV PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY:any D FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/51TE APPLIGAI wn, r V nm h , ui%LrQo M V V nncn • ��/�•� ^ • •^� �__•• • •-__ DATA PROCESSING COPY