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STATFpOF20,AWOR& WATER RESOURCES CONTRAOARD MMMF'f ENTAL HEA(p# DERGROUND STORAGE TANK PROGRAM #91452D lu TANiICIT/SE iii TANK PERMIT APPLICATION INFORMATION A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑X 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED l FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 j f,IT44?H Bi l l Parks Chev Ton FARM TANK-YES❑ NO Fxl I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK ID N WC5720C B. MANUFACTURED BY: ------ C. YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 1,000 gallons II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT X❑ 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 HAZARDOUS SUBSTANCE STORED&C.A.S.K C.A.S.W NA III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EYfER10R LINER ❑95 UNKNOWN SYSTEMX❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 10076 METHANOL COMPATIBLE FRP 9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYO LINING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑ LINING 5 GLASSUNING ❑6 UNUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METH4NOL? E]YES [:j NO ❑99OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑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 A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U %UNKNOWN A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U 99 OTHER A U 1 STEEUIRON AOI 2 STAINLESSSTEEL 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 STEELCLADW/FRP A U 8100%METHANOLCOMPATIBLEFRP 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 t I VISUAL CHECK 6 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P t 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURE TESTING P E 91 NONE P S 95 UNKNOWN P S 99 OTHER- VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLOMB INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENAL ERJURY,4M Tq TH S F MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE 1)NIC) C.'., ao vkos-ls S - LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FA ILITY ID• TANK ID CURRENT LOCAL AGENCY FACILITY ID t APPROVED BY NAME PHONE 0 WITH AREA CODE CHIC V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / ( /1 CHECK 0 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 0 BY: FORMB(6-29-BB) THLRFORMMUSTBEBYAFACIL MAYTEANSA moN, FORM'A', ACUMIENT DBM'M IMSIEENRLED 1''°�AIRED PROCESSING COPY 2 LOCAL AGENCY F 3 1"COPY