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r STATE OF CALIF�IA WATER RESOURCES CF"OL BOARD FORM IB': NDERGROUND STORAGE TANffROGRAM 1 TANK TANK PERMIT APPLICATION INFORMATIONm • `° COMPLETE A SEPARATE FORM WITH THE FOLLnwIAIn INCnOMATInN �..e �..... MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM dINTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED �y FACILITY/SITE NAME WHERE TANK IS NAME WHERE TANK IS INSTALLED: Zd L PA FARM TANK VES ❑ NO ©FARM TANK VES ❑ NO ©� v uv n l VINVLL It ALL ITEMS • IF UNKNnWN _ sn CGCr¢v A. OWNERS TANK ID # B. MANUFACTURED BY C. YEAR INSTALLED ?77 / I D TANK CAPACITY IN GALLONS 1 7 " ooe5 TAkIIC rAWTC\ITC ._._ .. ._ A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM DOUBLE WALLED C. ❑'♦'UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ODUCT F ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWNSTE ❑ 99 OTHER ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN ROY A R r A n A. TYPE OF DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-] 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. TANK 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP 1 SINGLE WALLED A ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 5 GLASS El2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOLIC LINING LINING LINING 6 UNLINED A ❑ 95 UNKNOWN 4 FIBERGLASSPIPE A ❑ ISUNING MATERIAL COMPATIBLE WITH 10D%METHANOL9 ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY. A PRIMARY LEAK DETErTInN QVQTFu U.I.T Rt r,nn, c - VI. P S IVISUALCHECK S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CI nsFn IN DI ArF 1. ESTIMAT PATE LAST USED (MO/VR) Z ESTIMAT D QUANTITY OF 3. WAS TAN F LED WITH A SUS REMAINING IN GALLONS IN�q�y( L? El YES ❑NO Y� � THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PFRJI IRY ANO Tn THP PIPET nr AAV WAInlAn cncr .o Tom, 11 A 11- ,.,..,---- APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY IAAF ANI v COUNTY # JURISDICTION # ....... n u, v it vnutmumu UNU, UVIH IF APPLICABLE FACILITY ID R TANK ID M A. SYSTEM TYPE A$ 1 SUCTION q 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 A U 95 UNKNOWN A U 99 OTHER CHECKN A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL. A A U U 5 ALUMINUM A 9 GALVANIZED STEEL A 6 CONCRETE 95 UNKNOWN A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY. A PRIMARY LEAK DETErTInN QVQTFu U.I.T Rt r,nn, c - VI. P S IVISUALCHECK S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CI nsFn IN DI ArF 1. ESTIMAT PATE LAST USED (MO/VR) Z ESTIMAT D QUANTITY OF 3. WAS TAN F LED WITH A SUS REMAINING IN GALLONS IN�q�y( L? El YES ❑NO Y� � THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PFRJI IRY ANO Tn THP PIPET nr AAV WAInlAn cncr .o Tom, 11 A 11- ,.,..,---- APPLICANTS NAME (PRINTED 6 SIGNATURE) DATE LOCAL AGENCY IAAF ANI v COUNTY # JURISDICTION # AGENCY # FACILITY ID R TANK ID M UO s 66 D CURRENT LO L AGENCY FACILITY,lB # APPROVED BY MALfEE PHONE N WITH AREA CODE Cs�.��\/ PERMIT NUMBER PERMIT APPROVAL DATE PER T EXP ATION DATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B (6-29-88) THIS FORM MUST BE ACCO MPAN BYAFACILITY/SITE APPLICATION, FORM A', UNLESS URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY 0 Z FO FV .p► F-�