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STATE OF CALIFORN _ WATER RESOURCES CONTR �1JOARD FOR NDERGROUND STORAGE TANK PROGRAM TA ►NK PERMIT APPLICATION INFORMATION " mo CC��1�uupplJ1MAY,n� ApFW� E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Ma1TWRO NM NL FT Lh11LTH ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE I _tM VV RMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: T3 HOL r r 5#115 1 FARM TANK-YES❑ NO O I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# _752-4- 4.+.53 17%U - I I B. MANUFACTURED BY: Ffi M C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 10V Ow q^L-Lp/V`l cn II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. / C. 1 UNLEADED El LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL I v l I 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM f 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL [:]3 RBERGUSS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑1 RUBBERUNED ❑2 DINING F-13 EPDXY LINING ❑4 PHENOLICUNING LINING ❑5 GLASS LINING 6 UNUNEL ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METIMOP -]YES ❑ NO ❑99 OTHER D. CORROSION ❑) POLYETHLENE WRAP ❑2 TAR OR ASPHALT n 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION II J`yl 5 CATHODIC PROTECTION ❑91 NONE `Llaj&UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTIONU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 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 A01 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 1 OD%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 VISUALCHECKP 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S PRECISION TESTING 8 7 PRESSURETESTING P S 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. 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 INOALLONB 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(PRIME SIGNATURE) -� DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRELOCAL AGENCY FACILITY ID 4 APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT .J[URCNARGE AMT. FEE CODE RECEIPTR BY FORM B(6-2s-es) THIS FORM MUST BE ACCOMPANIED A FACILRY/SRE APPLICATION, FORM 'A',UNLESS A CIARENT FORMA HAS BEEN FILED )o- ( — — DATA PROCESSING COPY ___