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STATE OF CALIFORNI f& WATER RESOURCES CONTROARD FORM W: UNDERGROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANX ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED (�r FACILITY/SITE NAME WHERE TANK IS INSTALLED: a, FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO CIFY iC A. OWNERS TANK ID# B. MANUFACTURED BY: (f C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 7 3 ��Qj 7�-w II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,COMPLETE ITEM D. 1I A. [jXMOTOR VEHICLE FUEL [1) 2 PETROLEUM C. 1 UNLEADED DED E] 3 DIESEL ❑ 3 CHEMICAL PRODUCT F-] B.4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑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 J� HAZARDOUS SUBSTANCE STORED&C.A.S.# �(/ C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A A TYPE OF ❑ 1 PUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEOUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOLCOMPARBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STE0. ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2_490 LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC UNI NO C. INTERIOR LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? DYES 0 N 0 9 OTHER D. CORROSION ❑ 1 PO ETNENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL jn95 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. gllcl8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S d ELECTRONIC MONITOR P S S GROUNDWATER MONITORING WELLS p PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE' P S 95 UNKNOWN P S 99 OTHER kol I. 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 BEE 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 ID# TANKID# L CAL AGENCY FACILITY ID# APPROVED YNA E PHONE#WITH AREA CODE BER PERMIT APPROVAL DA� PERMIT EXPI ON DATE PERMIT AMOUNT SURCHARGEA FEE CODE RECEIPT BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIO BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY