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E OF CALIFORNII WATER RESOURCESCONTRO' —OARD IM 'B': UNDErGROUND STORAGE TANK PRCr6RAM GO �N TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT b 5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOS NK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMEENNDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ffleTANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 9 i S7 J 'GFARM TANK-YES NO ❑ •� iANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPE IFY A. OWNERS TANK ID N F. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �f O It. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 3 NOTOR VEHICLEAL FUEL ❑2 PETROLEUM B PRODUCT C ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5/HAZARDOUS ❑ 80 EMPTY ❑95 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.# CA.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A o A TYPE OF ❑1 DWBLEWNLEO ❑9 SINGLE WALLED WITH EXTERIOR UNER UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TAME ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMI ❑8 100%MMMOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL KNOWN ❑W OTHER ❑ 1 1UEIBERUNED ❑2 ALKYDUNING ❑3 EPDXY UNING �A❑�`44'PHENOLIC LINING C.LINING 5 GLASS UNING ❑6 UNUNED L �' NOWN LINING ❑ ❑IS UNING MATERIAL COMPATIBLE WITH 10016 METHANOL? ❑YES ❑ NO OTHER D.CORROSION ❑ 1 PDLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 V LWRAI, ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑W OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ( A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE U 5 UNKNOWN A U 99 OTHER B.CGNBTRUCTIGN A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 9 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 5ALUMINUM A CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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. N 6 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOLAR) 2.ESTIMATED QUANTITY 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY* ILITY ID# TANK ID# CURRENT LOCAL AGE APPROVED BY NAM PHONE#WITH AREA CODE I S M W 0 P Z-e,- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE a.:.. �RECEIPT BY: Jq(/Y• FORM B(&29--66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SRE APPLICATION, FORM 'A',UN RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY