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STATE OF CALIFORN WATER RESOURCES CONTR 30ARD FORM W: UNDERGROUND STORAGE TANK PROGRAM T TANK TANK PERMIT APPLICATION INFORMATIONp COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Ic MARK ONLY 71'>EW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 13-I Cl FARM TANK-YES❑ NO C,Tt I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED , D. TANK CAPACITY IN GALLONS: II. TANK CTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [Erl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 1 PR 4 OIL ODUCT ❑ 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.#: N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A. TYPE OF ❑ 1 DLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2!yid WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOLCOMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 AL LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING UNLINED ❑95 UNKNOWN ✓ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO �OTHER L)IQ D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 qR16R ASPHALT ❑ 3 VINYL WRAP ❑4 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 O 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 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 05 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAr D(MO/YR) 2. ESTIMATED QUANTITY OF WAS TANK FILLED WITH N SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NC GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY TA COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# E51 Uy 1 `-f Ovc CU77] RRENT LOCAL AGENCY FACILITY IDM APPROVED BY NAM PHONE K WITH AREA CODE �eJe 1p I� LPFRMIT NUMBER PERMIT APPROVArL�D'9 PER IT EXPIRATIO ATE 10 V; ��,/. CK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIc.i 8Y A FACILITY/SITE APPLICATION, FORM `A',UNLESS -URRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY