SITE INFORMATION AND CORRESPONDENCE

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STATE QF-CALIFORN' WATER RESOURCES CONTE BOARD .:.. ,�. FORM'S'• UNDERGROUND STORAGE TANK PROGRAM TANK : TANK PERMIT APPLICATP!! O AT ON I. m COMPLETE A SEPARATE FORM WITH THE FOLLFORMATION FOR.EACF>f TANK. m RK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 1 O E ITEM ❑2 fhRERIM PERMS OF INFORMATION ` ❑7 PERMANENTLY CL ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O [FA;CILM/SjrE NAME WHERE TANK 18 INSTALLED:" i I FARM TANK-YES 140 � L.TANK DESCRIPTION COMPLETE ALI.ITEMS-fF UNKNOWN—SO SPECIFY co i--� A. OWNERS TANK ID#' y 00B. MAN61AC7URED.SY: 00 C. YEAR INSTALLED i s D. TANK CAPACITY IN GALLONS: I 1 ,I 11. TANK CONTENTS ..'IF(A 1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. aO I-MOTOR VEHICLE FUEL A. 3 CHEMICAL PRODUCT ❑4 PETROLEUM 8. ! C. 1 UNLEADED ❑ I ❑ ❑2 LEADED ❑3 DIESEL IL ❑ 1 PRODUCT E ❑4 GASAHOL ❑5 JET FUEL ❑fi AVIATION GAS ❑5 HAZAADOUS _ ❑80 EMPTY 95 UNKNOWN ❑2 WASTE I� ❑7 METHANOL ' ❑99.OTHER(DESCRIBE IN ITEM D,BELOW) ' D, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF j HAZARDOUS SUBSTANCE STORED&C.A.S.# !I If III. TANK CONSTRUCTION MARK ONE ITEM ONLY 1N BOX 4 B,c,a D. ;! A.TYPE OF :''.. ❑T DOU81E WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 11 ®95 UNKNOWN I " SYSTEM ❑4 SECONDARY CONTAINMENT ❑99 OTHER I ❑ I B.TANK '' S ❑2 STAINLESS STEEL 3 FIBERGLASS ;I❑4 STEEL CLADWIRBERGLASS'R€IHFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM _ I ❑8 IOD%METHANOL COMPATIBLE FRP ❑9 BRONZE:, ❑ 10 GALVANIZED STEEL } O 99 OTHER " C.INTERIOR ❑ 1 RUBBER LINA ❑2 AU(1 D LINING ❑3 EPDXY LINING I ❑4 PHENOLIC LINING _ UNING E]5 GLASS LINING6 UNLINED Ii . ❑ I95 UNKNOWN S LINING MATERIAL. TER COMPATIBLE WITH 10096 METHANOL I' ❑ 7 ❑YES ❑NO I�❑99 OTHER I . D.CORROSION ❑ 1 POLYERILENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP .j❑4 FIBERGLASS REINFORCED PLASTIC I PROTECTION" ❑5 CATHODIC PROTECTION ❑91 NONE ®95 UNKNOWN !❑99 OTHER IV. PIPING INFORMATION 'CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE" 'IP A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WAILED A U 3 LINEOJTRENCH A U 91 NONE AQ95 UNKNOWN A U 99 OTHER I) 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 1 C MATERIAL m . A U 5 ALUMINUM A U B CONCRETE" A U 7 STEELfCLAD W/FAP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A©95 UNKNOWN A U 99 OTHER 'F W LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 7 1p1 VISUALOHECKP 8 2 INVENTORY RECONCILIATION P 8'3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P8 15 GROUND WATER MONITORING WELLS '8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE f©8 95 UNKNOWN P .8 199 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE.UkST USED(MO/YR) 2.ESTIMATED QUANTITY OF I' 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATEAlAL7 SlYES:[::]:NO �I n f :] TN1S FORM HAS BEEN.COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) !' DATE LOCAL AGENCY USE ONLY a 1 COUNTY,N JURISDICTION# AGENCY# IFACILITY 10# TANK ID# El Ll-- 0 lolol -ZIN ��- Fo oloill CURRENT LOCAL AGENCY FACILITY ID 8 APPROVED BY NAIVE PHONE#YYITH AREA CODE N PERMIT NUMBER. PERMIT APPROVAL DATE PERMIT EIIRIRATION OATH. I` CHECK/ PERMIT AMOUNT RCNMGE AMT. FEE CODE IPT 0 BY: I • FARM 8(5-29-Bfi) THIS FORM MUST BE ACCOMPANIE A FACIL[TY151TE APPLICATION, FARM`A',UALE$S A RENT'fOR1A'A' HAS BEEN FILED DATA aRnr._�cclnlr•._r._nov�•. -�.: "- � ..P. � ----.. -.. - -- -