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O� C LIFORA WATER RESOURCES CONTR&OARD ".. Fd S L 1^ UNDERGROUND STORAGE TANK PROGRAM #91452B ENV I IAL `'F ALS ii TANK PERMIT APPLICATION INF MATION ERV ICL�MPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT X❑ 3 RENEWAL PERMIT 1!105' CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACiLITYYSITE NAME WHERE TANK IS INSTALLED: Bill P3TICS CITCVT0IT FARM TANK-YES❑ NO ❑X I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDM 3 WC572UC B. MANUFACTURED BY: ------ C.YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 5,000 gallons 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑1 UNLEADED ®2 LEADED ❑3 DIESEL ❑3 CHEMICALPRODUCT ❑4 OIL X❑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 HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.N: 8006619 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ i DOUBLEWAIIB) ❑3 SINGLE WALLEDWRH EXTERIOR LINER ❑%UNKNOWN SYSTEM ©2 RNGLEWALIID ❑4 SECONDARYCONTAINMENT ❑99 OTHER ❑1 STEELARON ©2 STAINLESS$TEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIRBEBGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 I0011IMETHANOL COMPATIBLE RIP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOUCUNING C.INTERIOR 5 GLASSUNING ©6 UNLINED ❑95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE NTH 1011%METHANOL' ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLBIEWMP ❑2TAR OR ASPHALT ❑3WNYLWIMP ❑4 FIBERGLASSREINFORCEOPLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U / SUCTION 0 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 9/ NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON 4 2 STAINLESSSTEEL A U 3POLYVINYL CHLORIDE(PVC) A U IFIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 9100%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 6 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P 6 95 UNKNOWN ► { 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLEDWITH SUBSTANCE REMAININGIN WLLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY URY,AN HE EIST KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE Dp4kD .b I+OS a tJ ( v I Ino LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY# FACT 1 ID N TANK ID N y / 16 16 1 r 1 70=— CURRENT CURRENT LOCAL AGENCY FACILITY ID 0 #10ATEPERMIT PE PHONE#WITH AREA CODE C#6 viP33 PERMIT NUMBER PERMIT APPROVAEXPIRATION DATE CHECKI pERMITAMOUNT SURCHARGE AMT. RECEIPT# BY:cz FORMB(629-66) THIS FORM MUSTKACmwAMIEDBYAFACB!(Ylm Amft=K FORM'A', q�MT FOM'N IMSBEENFILE.Dv LV 1 A PROCESSING COPY Na LOCAL AGENCY 3 FML COPT