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y- -".}-+' -.,. �.: }�..7c�- y'.T �;.. . xc Y,iV`e-.s'-��N...�„�_-�._�,r, '�I.t�;„;�dr 'x:�_��}•, <br /> STATE -OF CALIFORNIo 4 WATER RESOURCES CONTRQAnOARD <br /> FORMV: UNDERGROUND STORAGE TANK PROGRAM <br /> ! TANK TANK PERMIT APPLICATION INFORMATION ° <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. r, ,.a .> <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK I <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE R8 TANK REMOVED <br /> 10 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: I(p S5� V o J SQST J aPICY FARM TANK-YES 0 NO C4 <br /> 1. TANK DESCRIPTION COMPLETE ALL iTEMS-IF UNKNOWN--SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED 9?C) D. TANK CAPACITY IN GALLONS: 00 <br /> IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. © MOTOR VEHICLE FUEL f-] 2 PETROLEUM B. G. 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 a 7 METHANOL99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# CAS #: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A TYPE OF 1 DOUBLE WALLED 3 SINGLE WALLED WITH D(TERIOR LINER D 95 UNKNOWN <br /> SYSTEM NGLEWALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> I STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS E,4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B MATERIAL ❑5 CONCRETE . 6 POLYVINYLCHLORIDE 7 ALUMINUM F-]'6 IMMETHANOLCOMPATBLEFRP <br /> 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN E] 99 OTHER <br /> C.INTERIOR ❑ 1 RUBBERLINED ❑2 ALKYDLUNG 3 EPDXYLINING ❑ 4 PHENLIC LINING <br /> LINING ❑ 5 GLASS UNING 6 UNLINED UNKNOWN <br /> I$LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NOOTHER <br /> O.CORROSIONi POLYETHLENE WRAP 2 TAR OR ASPHALT E]3 VIFI.WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 5 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND.'U IFUNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE SUCTION A U 2 PRESSURE A- U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER <br /> A' U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) . A U 4 FIBERGLASS PIPE A 'U 91 NONE <br /> C MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 71 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL-A5 UNKNOWN A U 89 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1 VISUAL CHECK P.S 2 INVENTORY RECONCILIATION 'P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USEb.(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES NO <br /> !` <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS. TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> [FN <br /> UNTY# JURISDICTION$ AGENCY# FACILITY ID# TANK ID# <br /> L El I I Ll L.1 1 1 h I q-Fl I I T71 -il <br /> T LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> It1I M C tp 3 - <br /> I UMBEp PERMIT APPROVAL DATE PER IT EXPIRATION-bATE <br /> PEpMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# Y. <br /> FOAM B(6-29-88) THIS FORM MUST BE ACC-OMPANI A FACILITY/SRE AppLIC,4TI0N, FORM 'A',UNLESS QkNT FORMA' HA5 BEEN FILED <br /> LOCAL AGENCY COPY <br />