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STATE OF CALIFORNIA WATER RESOURCES CONTRO OARD � FORM `13% UND ROUND STORAGE TANK PR .. AM TANK PERMIT APPLICATION INFORMATION Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. TANK MARK ONLY ❑ 1 NEW PERMIT ❑;4;A NEWAL PERMIT ❑5 CHANGE OFINFORMATION ❑7 PERMANENTLY CLOSED TANK ENDED PERMIT ❑6 TEMPORARYTANK CLOSURE ❑6 TANK REMOVED ONE ITEM ❑21NTERIM PERMIT ❑ FARMTANK-YES❑ NO ❑_ FACILITY/SITE NAME WHE.......S INSTALLED: co I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY }� e. MANUFACTURED BY: A. OWNERS TAI I ID# 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,COMEPALOETOE ITEM D. B. 2 LEADED ❑3 DIESEL A. ❑ 1 MOTOR VEHICLE FUEL [:] 2 PETROLEUM -.DIP RODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICALPRODUCT F-14 OIL 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,!D 3 SINGLE WALLED WITH EXTERIOR UNER ❑..95 UNKNOWN A TYPE OF ❑ 1 DOUBLEWALLED ❑99 OTHER SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT F-13 FIBERGLASS 4 STEEL CLAD WIFlBERGLASS REINFORCED PLASTIC F-1 1 STEEUIRON ❑2 STAINLESS STEEL B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6199%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOR ❑6 UNLINED ❑95 UNKNOWN LINING ❑ SGIASS LINING F-1 IS LINING MATERIAL COMPATIBLE WITH 10996 METHANOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑ 1 POLYETHIENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLVIflAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE rC. STEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER NSTRUCTION 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 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 ATERIAL AU S ALUMINUM A U fi CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P S 4EUNKNOWN MONITOR P S 559GRROENND WATER MONITORING WELLS P S 1VISUAL CHECK P 8 191 NONE P S 6 PRECISION TESTING P S I PRESSURETESTING - VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE &WASTANKFILLEDWITH 2.ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO 1. ESTIMATED DATE LAST USED IMO/VR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# AGENCY# FACILITY ID# COUNTY# JURISDICTION � m APPROVED BY NAME PHONE N WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDN PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 'ECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: (6-29-BB) THIS FORM MUST BE ACCOMPANIED BY CILITY/SITE APPLIFlLE N, FORM'A',UNLESS R FORMA' HAS BEEN FILED