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CURRENT LO(50;4L AGENCY FACILITY ID # <br />11) FD - <br />RECEIPT # <br />STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD <br />FORM <br />TANK <br />UNDERGROUND STORAGE TANK PROGRAM <br />TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br />1 NEW PERMIT 7 3 RENEWAL PERMIT <br />2 INTERIM PERMIT 7 4 AMENDED PERMIT <br />7 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br />7 6 TEMPORARY TANK CLOSURE <br /> 1 1 8 TANK REMOVED re7/7 <br />MARK ONLY <br />ONE ITEM <br /> <br />1 <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7/0 u.)( FARM TANK - YES I 1 NO 1 1 <br />A. OWNERS TANK ID 8 1(1 7 B. MANUFACTURED BY: <br />YEAR INSTALLED / 9 rCo D TANK CAPACITY IN GALLONS / Cl/ (00 ? 1TL ,4 ::.7_ <br />A.1L IS MARKED COMPLETE ITEM C. IF A.1 , IS NOT MARKED, COMPLETE ITEM D - - - - - 7-- - - - - - - , <br />A.I L'rl MOTOR VEHICLE FUEL 2 PETROLEUM <br />3 CHEMICAL PRODUCT 4 OIL <br />I I 5 HAZARDOUS 80 EMPTY 95 UNKNOWN <br />B. <br />PRODUCT <br />2 WASTE <br />C. 1 UNLEADED <br />I 1 4 GASAHOL <br />7 METHANOL <br /> 2 LEADED 7 3 DIESEL <br />I 5 JET FUEL 1 I 6 AVIATION GAS <br />j 99 OTHER (DESCRIBE IN ITEM D, BELOW) <br />IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF <br />HAZARDOUS SUBSTANCE STORED 8 C.A.S. q C.A.S. 8: <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. B, C, & D <br />TYPE OF <br />SYSTEM <br />I I 1 DOUBLE WALLED <br />F-7 2 SINGLE WALLED <br />ri 3 SINGLE WALLED WITH EXTERIOR LINER <br />4 SECONDARY CONTAINMENT <br /> I 95 UNKNOWN <br /> I 99 OTHER <br />TANK <br />MATERIAL <br />1 STEEL/IRON <br />5 CONCRETE <br />9 BRONZE <br /> 2 STAINLESS STEEL <br />6 POLYVINYL CHLORIDE <br />10 GALVANIZED STEEL <br />7 3 FIBERGLASS <br />I j7 ALUMINUM <br />I I 95 UNKNOWN I99 <br /> I 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br />8 100% METHANOL COMPATIBLE FRP <br />OTHER <br />INTERIOR <br />LINING <br />1 RUBBER LINED 2 ALKYD LINING <br />I 1 5 GLASS LINING 6 UNLINED <br />[--] IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? <br />3 EPDXY LINING <br />YES NO <br />j4 PHENOLIC LINING <br /> I 95 UNKNOWN <br />99 OTHER <br />CORROSION <br />PROTECTION <br />I 1 POLYETHLENE WRAP I 1 5 CATHODIC PROTECTION <br />2 TAR OR ASPHALT <br />I 1 91 NONE <br />I 3 VINYL WRAP <br />In 95 UNKNOWN <br />I <br />J <br />I4 FIBERGLASS REINFORCED PLASTIC <br />99 OTHER <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND U IF UNDERGROUND, BOTH IF APPLICABLE <br />SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br />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 />MATERIAL <br />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 <br />A U 5 ALUMINUM A U 6 CONCRETE A U 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 />S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />1 ESTIMATED DATE LAST USED (MO/YR) <br />GALLONS <br />2. ESTIMATED QUANTITY OF <br />SUBSTANCE REMAINING IN <br />3 WAS TANK FILLED WITH <br />INERT MATERIAL' 1 1 YES 1 1N0 <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br />APPLICANTS NAME (PRINTED & SIGNATURE) <br /> DATE <br />LOCAL AGENCY USE ONLY <br />I0 <br />COUNTY # JURISDICTION AGENCY FACILITY ID $# TANK ID <br />7 3 3 <br />APPRO D B NAVE PHONE # WITH AREA CODE <br />PERMIT NUMBER <br />CHECK # PERMIT AMOUNT <br />PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br />SURCHARGE MT. FEE CODE BY: <br />FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A ilACILITY/SITE APPLICATION FORM 'A', UNLESS A CURRENT FORM 'A' HAS BEEN FILED <br />f)T 2EtPrFcCIA1r rnpy