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-7 Y� d STkTE OF CALIFORNIA WATER IESOURCES CONTROL BOARD ORMV: UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY D' NEW PERMIT ❑3 RENEWAL PERMIT E]5 CHANGE OF INFORMATION [:]7 PERMANENTLY CLOSED TANK ONE ITEM E]2 INTERIM PERMIT ❑4 AMENDED PERMIT E16 TEMPORARY TANK CLOSURE E]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:;6��L-l— e,[4A-re--TE c:;;z FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOW d—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS. 2 oe5?15:) CA) 11. TANK CONTENTS IF(A.11),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM D. A. E]IA-MOTOR VEHICLE FUEL F-1 2 PETROLEUM B. C. Ej I UNLEADED E�J�LADED ❑3 DIESEL F-1 3 CHEMICAL PRODUCT F-1 4 OIL �PRIODUCT ❑4 GASAHOL ❑5 JET FUEL 6 AVIATION GAS [—]5 HAZARDOUS [::]80 EMPTY []95 UNKNOWN ❑2 WASTE El 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. xIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a 0 A.TYPE OF E21-I-tIOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN SYSTEM [:]2 SINGLEWAU.ED 1:1 4 SECONDARY CONTAINMENT [:]99 OTHER ❑ IL TANK 1 STEEUIRON F-12 STAINLESS STEEL [ZjJ-MtRGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE F-1 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE [:] 10 GALVANIZED STEEL [:]95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBER LINED Ej 2 ALKYD LINING r-13 EPDXY UNING E]4 PHENOUCUNING LIKING F-1 5 GLASS LINING JNUNED F-1 95 UNKNOWN E]IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E:]YES [::]NO [:]99 OTHER D.CORROSION ❑1 POLYETHLENE WRAP r--j 2 TAR OR ASPHALT F--j 3 VINYLWRAP ❑-4-fI8ERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION E]91 NONE 96 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 PRESSURE A U 3 GRAVITY A U 99 OTHER IL CONSTRUCTION A U I SINGLE WALLED A DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN- A U 99 OTHER A ti I STEEL/IRON A U 2 STAINLESS STEEL A Ul 3 POLYVINYL CHLORIDE(PVC) A<:5?FIBERGLASS PIPE C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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. I VISUAL CHECK P 0 2 INVENTORY RECONCILIATION P '0 3 VADOSE WELLS(:j!�h 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE' P 8 95 UNKNOWN P 3 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 SUBSTANCEREMAINING IN GALLONS INERT MATERIAL? (DYES [:]NO THIS FORM HAS BEEN CqMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLIC S N (PRI SIGNATURE) 7] DATE - j I /--/ I Z-1 k24 L zf4z:;� LOCAL AGENCY USE ONLY COUNTY 0 JURISDICTION 0 AG NCY 0 FACILITY ID TANK 10 0 I Ell I I ❑ CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 0 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE. CHECK 0 PERMIT AMOUNT. SURCHARGE AMT., FEE CODE RECEIPT# cyl. FORM 13(3-7-w) THIS FORM MUST BE ACCOMPANI A FAciuTy/srrE AmcnoN, FORM W,uwm.k%��RENTFORWX HAS BEEN FRED LOCAL AGENCY COPY