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a. n .., f. ... ice. . STATE OF CALIFORNI/O WATER RESOURCES CONTROARD FORM BI: UNDERGROUND STORAGE TANK PRO AM �Q TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. "" II TANK MARK ONLY ❑PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSETANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED N i FARM TANK-YES❑ NO ❑ FACILITY/SITE NAME WHERE TANK IS INSTALLED: Ln I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN B. MANUFACTUREDBY:D. TANK CAPACITY IN GALLONS: C. YEARINSTALLED E�EEE II. TANK CO ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(AA),IS NOT MARKED,CO LETE ITEM D. A. i MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. T C. 1 ❑ 2 LEADED ❑ 3 DIESEL ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUC 5 HAZARDOUS 60 EMPTY 95 UNKNOWN 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) ❑ ❑ ❑ ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A.TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER NKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ i STEEUIRON ❑ 2 STAINIESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD WIRBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 AUUMkM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER F-11 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENO LINING C. INTERIOR F-15 GLASS LINING ❑6 UNLINED UNKNOWN LINING ❑ MATERIAL II - IS LINING MATERIALCOMPATIBLEWITH 10096 METHANOL? ❑YES ❑ NO ❑ 990THER . D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINY// P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE NKNOWN ❑99 OTHER --- IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 p U 5 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 5ALUMINUM A U 6CONCRETE A,,U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A OD5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK -a S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S A 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 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 1.ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO / GALLONS THIS FORM HAS EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, .. DATE APPLICANTS NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY X JURISDICTION N AGENCY N FACILITY ID M TANK ID X D oZ2- s vo o / [PERMIT RRENT LOCAL AGENCY FACILITY ID X APPROVED BY ME PHONE X WITH AREA CODE NUM ER PERMIT APPR VAL DATE P MITEKPIRATI DATE CHECK# PERMIT AMOUNT SURCHARGE T. FEE CODE RECEIPT# BY: FORM B(6-29-68) THIS FORM MUST BE ACCOMPANIE Bf A FACIUTYPION, FORD A',UNLESS A UNRENT FORMA HAS BEEN FILED DATAPROCESSING