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,O.PCALIFORNIA WATER'RESOURCES CONTROL BOARD •':�:.'• <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> _ TANK PERMIT APPLICATION INFORMATION <br /> �,•-• , .:,>, ;:COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK. <br /> "} . MARK ONLY %•'„•D 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PPW0ENTLY CL K ' <br /> ONE ITEM {,: ;>'.❑2 INTERIM PERMIT ❑4 AMENDED PERMIT. ❑6 TEMPORARY TANK CLOSURE TANK REMOVED <br /> W <br /> bil <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z 5 /nAG FARM TANK-YES NO ❑ (V <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID N ” B. MANUFACTURED BY: <br /> YEAR INSTALLED Llj< 0. TANK CAPACITY IN GALLONS: DD <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT' ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED S CAS.N, C.A.S.It <br /> I11: TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,i D <br /> A.TYPE OF ' • ❑ 1.DOUBLE WALLED D 3 SINGLE WALLED WITH EXTERIOR LINER D 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER <br /> ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 RBERGUISS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 8.TANK :':❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑T ALUMINUM ❑e I00%METHANOL COMPATIBLE FRP <br /> ;. •:❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN D 99 OTHER <br /> C.INTERIOR.' ', .•D 1 RUBBER UNED. .. ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING <br /> LINING, . ;'. ❑5 GLASS LINING [36 UNLINED ❑95 UNKNOWN <br /> . '❑ IS LINING MATMAL COMPATIBLE WITH I W%MMWIOL? ❑YES ❑NO D 99 OTHER <br /> D.CORROSION ❑ 1.POLYETHLENEWRAP . ❑2 TAR ORAWMT D 3 VINYLWRAP ❑4 RBERGLASSREINFORCEDRASTIC <br /> PROTECTION ❑5 CATHODICPROTECTKkI D 91 NONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U I SUCTION A U 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 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL ' A U 5 ALUMINUM A U 8 CONCRETE A V 7 STEEL CLAD W/FRP A U 8 100%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 B 1 VISUAL CHECK P 1 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P B 4 ELECTRONIC MONITOR P f 5 GROUND WATER MONITORING WELLS <br /> P f 8 PRECISION TESTING P B 7 PRESSURE TESTING P 8 91 NONE P B 95 UNKNOWN P B 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED GATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY Of 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT AALLONf MATERIAL? ❑YES ❑NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO — <br /> THE BEST OF AAY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION 41 AGENCY I FACILITY ID I <br /> TANK ID S <br /> L 1 1 .1 L 1_j I _L I- I / I �ITT I T 1 .2-4 <br /> CURRENT LOCAL At3ENCY fACILITY 10 f APPROVED BY NAME PHONE I WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATION DATE <br /> CHECK f PERMIT AMOUNT SURCHAROE AMT. <br /> A. FEE CODE ECEIPT <br /> ~ "cqm"q w TH1O rte..,,u„rT <br />