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W+ <br /> -STATE OF CALIFORNIA WATER OESOURCES CONTROL BOARD <br /> FORM W: UNDERGROUND STORAGE TANK PROGRAM <br /> TANS( TANK PERMIT APPLICATION INFORMATIONo <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z <br /> Ip i <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERMANENTLY CLOSED TANK i <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED 0- <br /> FACILITY/SITE <br /> - <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (� <br /> I-y <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 40 <br /> A. OWNERS TANK ID q <br /> Q B. MANUFACTURED BY: `�� C=) i <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: � <br /> II. TANK CTENTS IF(A 11,18'MARKED,COMPLETE ITEM C.IF(A-11),IS NOT MARKED,COMPLETE ITEM 0. <br /> A. 1 MOTOR VEHICLE FUEL [ 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED IESEL <br /> 3 CHEMICAL PRODUCT F] 4 OIL 1 PRODUCT 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS j <br /> E]5 HAZARDOUS ❑ BO EMPTY 0 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&C.A.S.q � C.A.S.q: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> TYPE OF ❑ 1 WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> A II <br /> SYSTEM SING ALLfD 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEELIIRON 2 STAINLESS STEEL n 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK ! <br /> 5 CONCRETE �6 POLYVINYL CHLORIDE n 7 ALUMINUM �B 10096 METHANOL COMPATIBLE FRP � <br /> MATERIAL ❑9 BRONZE D 10 GALVANIZEDSTEEL 0 95 UNKNOWN E199 OTHER <br /> 1 RUBBER UNEP 2 ALKYD LINING 3 EPDXY LINING 4 PHENO LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED Eae <br /> NKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPAIiBLEWITH 100%METHANOL? ❑YES [:]NO ❑99 OTHER <br /> D.CORROSION ❑ I POLYETHLENEWRAP ❑2T RASPHALT 3VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORM TION CIRCLE A IF ABOVE GROUND,(U IF UNDERGROUNQ,BOTH IF APPLICABLE <br /> A SYSTEM TYPE U 1 SUC A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER- <br /> A. <br /> CONSTRUCTION 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 STEEL lIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> i <br /> C.MATERIAL M A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FOP <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 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION PSELLS WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S B PRECISION TESTING P 8 7 PRESSURE TESTING S 91 NONE P S 95 UNKNOWN <br /> P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> 1.ESTIMATED DATE LAST USED(MO/MRI SUBSTANCE REMAINING IN INERT MATERIAL? YES NO <br /> GALLONS <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 i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY#- (JU IS41CX1 I�I/-/ AGENCY M FACILITY ID N TANK ID M <br /> Eal DFdT3 9 1 In I In <br /> CURRENT LOCAL AGENCY FACILITY 10 0 APPROVED BY NAME PHONE 11 WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK 0 PERMIT AMOUNT f 'URCHARGE AMT. FEE CODE IPT M BW <br /> i - <br /> _.�ennu uuca nc arrnMD&NlPD RY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A'CURRENT FORMA' HAS BEEN FIL <br />