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,,,,NftvfoRrild} - z1,444.-fm,,,torver4% NEW PERMIT 2 INTERIM PERMIT 3 RENEWAL PERMIT I 1 4 AMENDED PERMIT pi 5 CHANGE OF INFORMATION I I 7 PERMANENTLY CLOSED TANK n 6 TEMPORARY TANK CLOSURE 7 8 TANK REMOVED STATE OF CALIFORNIA WATER RESOURCES CONTROL L.RD FORM TANK UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION CON,LETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 0/ I 0 MARK ONLY ONE ITEM I FACILITY/SITE NAME WHERE TANK IS INSTALLED: :P j ) 4), /1_) /.C13Y1 FARMTANK-YESI NO I I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID A 0 5 B. MANUFACTURED BY: C. YEAR INSTALLED / q e(G. D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. 1 MOTOR VEHICLE FUEL fl 2 PETROLEUM 3 CHEMICAL PRODUCT 1 [ 4 OIL I I 5 HAZARDOUS 7 80 EMPTY 95 UNKNOWN EV C.1 I 1 UNLEADED 4 GASAHOL 7 METHANOL I I 2 LEADED 1'13- DIESEL I 5 JET FUEL 6 AVIATION GAS 1 99 OTHER (DESCRIBE IN ITEM D, BELOW) 1 PRODUCT 2 WASTE D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. A C.A.S. A: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF 7 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR SYSTEM I I 2 SINGLE WALLED 4 SECONDARY CONTAINMENT LINER I 95 UNKNOWN 1 1 99 OTHER I I 1 STEEL/IRON 7 2 STAINLESS STEEL B. TANK I I 5 CONCRETE [ I 6 POLYVINYL CHLORIDE MATERIAL I I 9 BRONZE ri 10 GALVANIZED STEEL 1 I 3 FIBERGLASS 7 4 STEEL CLAD W /FIBERGLASS REINFORCED PLASTIC 1-7 7 ALUMINUM 8 100% METHANOL COMPATIBLE FRP 95 UNKNOWN I I 99 OTHER 1 RUBBER LINED I 2 ALKYD LINING C. INTERIOR LINING 7 5 GLASS LINING 1 16 UNLINED IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 3 EPDXY UNING 7 4 PHENOLIC LINING 95 UNKNOWN 7 YES 1 I NO 1 I 99 OTHER D. CORROSION 1 POLYETHLENE WRAP 2 TAR OR ASPHALT PROTECTION I Is CATHODIC PROTECTION 91 NONE 7 3 VINYL WRAP 7 4 FIBERGLASS REINFORCED PLASTIC 7 95 UNKNOWN I 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE 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 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 MATERIAL 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 A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W /FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 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 S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN GALLONS 3. WAS TANK FILLED WITH INERT MATERIAL? 7 YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # 3 JURISDICTION # AGENCY # FACILITY ID # TANK ID # CURRENT LOCAL AGENCY FACILITY ID A )11111E)-- PERMIT NUMBER CHECK A PERMIT AMOUNT APPROV BY NAME PHONE A WITH AREA CODE PERMIT APPROVAL"ØATE PERMIT EXPIRATION DATE / SURCHARG AMT. FEE CODE CEIPT FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION FORM 'A', UNLESS A CURRENT FORM 'A' HAS BEEN FILED CT •i1:11? 'Cr...C.C-1. • G. MX:6CW