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Apr STWAIA, VICALIFORNU WATER RESOURCES CONTRq' ARD 1'.) � F01�TM '' UNDERGROUND STORAGE TANK PROGMAM AY P 1 .1�"Q TANK PERMIT APPLICATION INFORMATION pp MENT /�++�� SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. " MANKET/SIpS1HRMIT 3 RENEWAL PERMIT '�5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: BE JJ {-p LT SNELL- FARM TANK-YES❑ NOCK 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 7524 -¢q,5,3 5U- I I B. MANUFACTURED BY: 7jHEE Am C. YEAR INSTALLED I 7Z D. TANK CAPACITY IN GALLONS: S C)oo C'3 ALLOIy5 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 PETROLEUMC. [011 UNLEADED ❑2 LEADED ❑ 3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 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.R C.A.S.#: j III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM F--] B 100%METHANOL COMPATIBLE FHP ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER . INTERIOR [:] 1 RUBBER LINED ❑ AU(YDUNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING C LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1M%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ tAIOLYETHUENE WRAP ❑2 TAR OR ASPHALT VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 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 U / SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A FIBERGLASS PIPE A U 91 NONE C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P(-5)P(-S)B PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY Of 3.WAS TANK FILLED WRH SUBSTANCE REMAINING INGALLONSINERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF YY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED NATURE) .JQ DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANKID4 CURREIIT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER 3DPERMIT APPROVAL DATE PERMIT EXPIRATION DATE ^� CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: (<• 1 FORM B(6-29aB) THIS FORM MUST BE ACCOMPANIEU A FACILITY/SITE APPLICATION, FORM`A',UNLESS A FORMA' NAS BEEN FlLED DATA PROCESSING COPY