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STATE OF CiALIFORN^ WATER RESOURCES CONTR' -�SOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM (aTANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED T ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO Ll I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ; A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLE D. TANK CAPACITY IN GALLONS: -r II. TANK TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT KED,COMPLETE ITEM D. r A. gi MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED DED E] 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑4 OIL B. PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ SO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION K ONE ITEM ONLY IN BOX A,B,C,a D r A TYPE OF ❑ 1 PJBffWALUED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGIE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEL71RON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL GAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONCRETE ❑6 POLMNYL CHLORIDE ❑ 7 ALUMI ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL NKIIOYM ❑ 99 OTHER ❑ I AWBERUMED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PH C INTERIOR F-15 GLASS LINING F-16 UNUNED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WTTH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAHORASPHALT ❑ 3 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 u. A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U t5 UNKNOWN U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NO A LANK W A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLAS PE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCIAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MD/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANPS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY# FACI l� TANK ID# _ q -0 � I � O � RE CAL AGENCY FACILITY IDN APPRO AME PHONE N WITH AREA CODE P PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY. SG r FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FAULITYISTTE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED