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STATE OF CALIFORNIA WATER RESOURCES CONTROARD FORM BI; UNDE GROUND STORAGE TANK PRO RAM S TANK PERMIT APPLICATION INFORMATION 77 TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE �ANK REMOVED Q r.,) Fwj- FARM TANK-YES❑ NO u FACILITY/SITE NAME WHERE TANK IS INSTALLED: U-2(5 -2 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A A. OWNERS TANK ID N f�(v ` 1 B. MANUFACTURED BY: �. f D. TANK CAPACITY IN GALLONS: C. YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C. ❑ 1 UNLEADED ❑ 2 LEADED A. [ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL i PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS E] 80 EMPTY E]95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF —_ C.A.S.N'. HAZARDOUS SUBSTANCE STORED&OAS,# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER E] 95 UNKNOWN A.TYPE OF ❑ ❑ SYSTEM ED-2SINGLEWALLED ❑4SECONDARY CONTAINMENT 99 OTHER ❑ I STEELIMON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS '4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 1 W%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN LININGF-] �I Thr IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL? ❑YES ❑ NO �0THER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH 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 FIBERGLASS A U LE NONE C.MATERIAL A U 5ALUMINUM A�CONCRETE A U 7STEEL CLAD W/FRP A U 810045 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(Z 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. S1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TES TING P S 7 PRESSURETESTING P S 91 NONE P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE awnsrANKFILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY% JURISDICTION% AGENCY% FACILITY ID% TANK ID# 3 q 0 c� 1 3 - APPROVED BY NAME PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDN c—CD I I/.� F- N[J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E IRATI N DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEECODE RECEIPT# BY: FORM a I6-29-e6) THIS FORM =UST ACCOMPA BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS C RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY