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STATE OF CALIFORNI Ak WATER RESOURCES CONTR" BOARD FORM IBI: UND"GROUND STORAGE TANK PRftRAM TANK TANK PERMIT APPLICATION INFORMATION " COMP ETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY UI'NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYNK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE /f FACILITY/SITE NAME WHERE TANK IS INSTALLED: / ;L 7-5-0RM TANK-YES ElNO •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SPECdY 75-376 A. OWNERS TANK IDR B. MANUFACTURED BY: w C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: i II. TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED, MPLETE ITE CIT A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED W LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASA IOL ❑ 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 l HAZARDOUS SUBSTANCE STORED&CA.S.R ' v C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF ❑ lA6UBUE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY COMAINMENT ❑ 99 OTHER ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 RBE ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 MINUM ❑8 lDD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERUNED ❑2 ALKYD UNING E]3 EPDXYUNINGrUNKNOWN NOUC LINING LINING F-15 GLASS LINING ❑6 UNUNED El IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NOHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TM OR ASPHALT ❑ VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMA TON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TFPE A U 1 RUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE -TI 5 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 95 UNKNOWN A U 99 OTHER 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 C.MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. 1 VISUAL(HECKP(3s) S 2 INVENTORY RECONCILIATION P 8 3 VAUOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I 'P 6 PRECISION TESTIN4 P 8 7 PRESSURE TESTING P B 91 NONE P 8 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 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES F] 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FACILITY IDN TANK ID N I 6f (01010 10 11 CURRENT LOCAL AGENCY FACIV10 0 APPROVED BY NAME PHONE I WITH AREA CODE , 1` A/ /X PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 1 By./- 'e FORM B(6-29-98) THIS FORM-UST BE ACCOYP IED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS;CURRENT FORM'W HAS BEEN FILED DATA PROCESSING COPY