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/.5.4R- T-r-t-7 STATE OF CALIFORK' WATER RESOURCES CONT(' 30ARD FUNDt<GROUND STORAGE TANK PROTRAM ' ? 1 Ir TANK PERMIT APPLICATION INFORMATION Y 211001PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ NIVpdN��E��xgFilMAENT/,ID�IHEEALPTHT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TAN TLfSIYIII /SEM-WI�C3"m PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑S TANK REMOVED FACIL(TY/SITE NAME WHERE TANK IS INSTALLED:Z)5" {-DLT G.I5 5HELL - FARM TANK-VES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY FA a II A. OWNERS TANK ID# -7S24- ^4-4,53 B. MANUFACTURED BY: aW 0:FR l INal C. YEAR INSTALLED '9$ D. TANK CAPACITY IN GALLONS: 550 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM D. C ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT S4 OIL I PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS M`J jZ5 HAZARDOUS ❑80 EMPTY ❑ 95 UNKNOWN 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) �\1 D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# WA5TI—= O(L- C.A.S.#: III. TANK CONSTRUCTION MARKONE ITEM ONLY INBOX A,B,C,AD A.TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM - 2 SINGLEWALIEO ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CUD W7FIBERGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE m 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL Ej 95 UNKNOWN ❑99 OTHER C.INTERIOR 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOUCUNING LINING 5 GLASS LINING �6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH I00%MEIHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP 2 TAROHASPHALT ❑3 VINYL WRAP4 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 A U 2 PRESSURE A(U)3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A CU 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 Ag I STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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 1 VISUAL CHECK P 8)2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLED B 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO7YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SI TURE) I I DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANKID# m CURB T LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE*WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: i FORM B(6-29-88) THIS FORM MUST BE ACCOMPANUiLi nY A FACILTTYRRTE APPLICATION, FORM`A',UNLESS AbARENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _