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STATE OF CALIFORI§A WATER RESOURCES CON&L BOARD <` ORM IB': UNDERGROUND STORAGE TANK PATION � ' ,> ° F TANK PERMIT APPLICATION Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O 7 ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ' NEW PERMIT 0 3 RENEWAL PERMIT NK REMOVED MARK ONLY ❑ ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE W ONE ITEM ❑ 2 INTERIM PERMIT FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: (� FY I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SB MANUFACTURED BY: A. OWNERS TANK IDH D. TANK CAPACITY IN GALLONS. Q O C. YEAR INSTALLED II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D.LEADED ❑3 DIESEL B C. ❑ 1 UNLEADED A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMAPRODUCT ❑ 4 GASAHOL E] 5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) F-15 HAZARDOUS E] 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.H'. HAZARDOUS SUBSTANCE STORED&C.A.S.H Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D UNKNOWN 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER A.TYPE OF F-11 DOUBLE OTHER SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ ❑ 3 FIBERGLASS � 4 STEELCLAD WIFIBERGLASS REINFORCED PLASTIC ❑ 1 STEEL71RON 2 STAINLESS STEEL 8100%METHANOL COMPATIBLE FRP B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE El ALUMINUM ❑ MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL t�P5 UNKNOWN ❑99 OTHER ❑2 ALKYD LINING 3 EPDXY LINING ❑4CPHENOLIC LINING F-1 �—* 1 RUBBERLINED 1>J UNKNOWN C.INTERIOR ❑ 5 GLASSLINING ❑6 UNLINED LINING ❑ IS LINING MATERIAL COMPATIBLE WITH I W%METHANOL? ❑YES ❑ NO 9 OTHER D.CORROSION ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC ❑ 1 POLVETHLENE WRAP ❑gg OTHER PROTECTION E] 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLENONE U 95 UrvKNowN A U s9 OTHER A.SYSTEM TYPE A u 1 sucnoN A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER IBERGLASS PIPE A A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 STOEEL CLALDW/ORPDE(PVC) R U B F90%METHANOL COMPATIBLE FRpNE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 95 UNKNOWN A 9 OTHER UST BE CIRCLED. V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM M P 5 3VADOSE WELLS P S B LECTRO NIC MONITOR P S 99OTHER GROUND WATER MONITORING WELLS p S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 6 PRECISION TESTING P S T PRESSURE TESTING P S 91 NONE 9 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO 1, ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOW TE Wi DGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID X AGENCYX 0:12qlFACT X COUNTY X JURISDICTION APPROVED BY NAME V V/ PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDX `, - _7_1C) �� VAL DATE PERMIT EXPIRATION DATE PERMIT NUMBER CHECK X PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIpf N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITYIISITEA PRO TION, NGFORMA',UNLESS v RENT FORMA HAS BEEN FILED