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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `BI: UNDERGROUND STORAGE TANK PROGRAM e* , TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 P ANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ED<TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1-jy FARM TANK-YES❑ NO •Q 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNO -SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: / W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: #P� II. TANK CANTENTS IF(A,1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,r ,PMVLETE ITEM D. CA A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. ❑1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ 3 CHEMICAL PRODUCT E]4 OIL PRODUCT ❑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.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM Fg4NOLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑W OTHER CANTERKM F-11 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING1NUNED ❑96 UNKNOWN 1 F-1IS LINING MATERIAL COMPATIBLE WITH 100%IAEIHANOL? ❑YES NO ❑99 OTHER D PROTECTION ❑ 5 CATHODIC PROTECTION LONE ASPHALT ❑95 UNKNOWN ❑99 OTHER INFON;ED PLASTIC IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION ACU SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP A U 8180%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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. y�I P 5 1 VISUAL CHECK [P/8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS I' I P 5 6 PRECISION TESTING 8 7 PRESSURE TESTING P 8 91 NONE P 5 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 N /L7 GALLONS SUBSTANCE REMAINING IN 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENTj.DCAL AGENCY FA�17# APPROVED Y , � PHONE#WITH AREA CODE fifv 1 If PERMIT NUMBER PERMIT APPROVAL DATE MIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(B-29-aB) THIS FORM MUST BE ACCOMPANIEL..-.A FACILITY/SITE APPLICATION, FORM �A�,UNLESS A ENT FORMA' HAS BEEN FILED DATA PROC-r,''PING C�1Pi