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OF'CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM '6'• , UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION' '• • INFORMATION <br /> y COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br /> 1� <br /> • •�'��,�:�'•' � i NEW PERMIT • 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 P MANENTLY C NK <br /> MARK ONLY.:- ❑ ❑ <br /> ONE ITEM �;_�. ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE TANK REMOVE <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: L52 5, lhac, ,[ FARM TANK•YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Q <br /> C <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT r74 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&CAS.N C.A.S.N: <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D <br /> A.TYPE OF ❑1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER <br /> B.TANK ❑ 1 STEEUiRON ❑ 2 STAINLESS STEEL F73 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL,;:..;❑S CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 6 IOD%METHANOL COMPATIBLE FRP <br /> ;.r .:❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> LINING•, ;':. ❑S GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN <br /> . '❑ IS UNING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑NO ❑ 99 OTHER <br /> D.CORROSION . ❑ lPOLYETHLENEWRAP ❑2 TAR 019MPI-IALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION •❑5 GlTH001C PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> k SYSTEM TYPE A U I SUCTION A V 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. 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 <br /> A U 1 STEELPRON A U 2 STAINLESS STEEL A V 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBEROLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1009 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 9 6 PRECISION TESTING P D 7 PRESSURE TESTING P 5 91 NONE P 5 95 UNKNOWN P 6 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF <br /> 3.WAS TANK FILLED WITH <br /> - SUBSTANCE REMAINING IN INERT MATERIAL? El YES ❑NO <br /> GALLONO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> - - APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N ' ',JURISDICTION* AGENCY# FACILITY ID N <br /> TANK ID N <br /> Ll 11 <br /> X63 / <br /> CURRENT LOCAL AGENCY FACILITY 10�,� APPROVED BY NA.M <br /> PHONE WITH AREA CO <br /> l N DE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK I PERMIT AMOUNT 6URCHAAOE AMT. FEE CODE �ECEIPT <br /> BY; <br /> wwomommuml <br /> FORM 9 m-in.nnl TH1s Frny 141 KT ne Arrr„�.,i, v. ��r ,. , �. -- •- <br />