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STATE OF CALIFORNI WATER RESOURCES CONTRI 30ARD fOFfM `13': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT�K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 5 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES a NO ❑ w 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ((N A. OWNERS TANK ID At B. MANUFACTURED BY: U V7 C. YEAR INSTALLED u/( D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(a1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL E]5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑00 EMPTY5 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.It: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELPRON ❑2 STAINLESS STEEL ❑3 RBERGtASS ❑4STEELCLADW/FIBERGLASSREINFORCEDPIASTIC B.TANK ❑5 CONCRETE ❑ B POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ MATERIAL 0 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL FE<5 UNKNOWN 09 OTHER ❑ C.INTERIOR i RUBBER LINED ❑2 ALKYD UNING F-] 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED Q-M'GKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES ❑ NO ❑99 OTHER F ION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC TION ❑5 CATHODIC PROTECTION ❑91 NONE NKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE AIFA13OVEGROUND. UIFUNDERGROUND,BOTH IFAPPLICABLE 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 WALLED A U 3 LINED TRENCH A U 91 NONE A UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. P B I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑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 R JURISDICTION B AGENCY B FACILITY ID 0 TANK ID u 4/ v i CURRENT��GENCY FACILITY ID APPROVED BY NAME PHONE R WITH AREA CODE PERMIT NUMBER EDyQI PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE I T. FEE CODE RECEIPT V' FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED Y A FACIUTYISAA TE APPLICATION, FORM 'A',UNLESS AL�RRENTFORMA' HAS BEEN FILED DATA PROCESSING COPY