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STATE OF CALIFO IA WATER RESOURCES COO OLBOARD gw',.a,. kE <br /> FORM 413% UNDERGROUND STORAGE TANK PROGRAM o. <br /> TANK PERMIT APPLICATION INFORMATION .= <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY 1p-1 NEIN PERMIT � 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE Ej 8 TANK REMOVED Q ' <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br /> ` FARM TANK-YES 0 NO - <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY L <br /> A. OWNERS TAN]11D If r =TA <br /> URED EtY:C- YEAR INSTAL /� ACITY IN GALLONS: / pd� CA) <br /> II. TANK_ CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CadI� <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL 00 <br /> 3 CHEMICAL PRODUCT � 4 OIL PRODUCT <br /> 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS F-1 80 EMPTY [:] 95 UNKNOWN 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.I1: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.IF <br /> xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> [:31 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A.TYPE OF <br /> SYSTEM SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEL/IRON F-1 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK � 5 CONCRETE F-] 6 POLYVINYLCHLORIDE 0 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL F-] 9 BRONZE 10 GALVANIZED STEEL �95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED Q 2 ALKYD LINING F-� 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR f-I 5 GLASSLINING r 6 UNLINED 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES [-] NO E]99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLFNE WRAP TAR OR ASPHALT ❑ 3 VINYL W9AP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION ❑ 91 NONE fl 95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 095 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> / P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> PRESSURE P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> Jf p 5 6 PRECISION TESTING P S 7 <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. E5TIMATEQ QUANTITY OF 3. WAS TANK"LLE WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL) YES 0 NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> FC,URRENT <br /> OUNTY ff JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> C� I 1I� oldolAPPRO E Y M / / / PHONEN WITH AREA CODE <br /> LOCA AGENCY FACILITY ID# ,A��'�f//�,,j���/�` <br /> -LOCAL � <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 7 ? <br /> CHECK# PERMIT AMOUNT SURCHARGE MT. FEE CODE RECEIPT# BY: <br /> FOR -7-88) THIS FORM MUST BE ACCOMPA Y A FACILITY/SITE APPLICATION, FORM `A',UNLESAWRENT FORM'AHAS BEEN FILED <br /> DATA PROCESSING COPY <br />