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STATE OF CALIFORNO WATER RESOURCES CONTIBOARD <br /> FORM `I3'' UNDERGROUND STORAGE TANK PROGRAM I �o <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 N ERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> MARK ONLY TANK <br /> ONE ITEM INTERIM PERMIT El 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FARM TANK-YES E NO <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: t I <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECT Y <br /> A. OWNERS TANK ID# t(/�✓ � ED. <br /> NUFACTURED BY: <br /> C. YEAR INSTALLED '("/ NK CAPACITY INGALLONS: <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. E] 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 7 METHANOL ❑ 99 OTHER{DESCRIBE IN ITEM b,BELOW} <br /> 5 HAZARDOUS F—] 80 EMPTY [:] 95 UNKNOWN 2 WASTE <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A-S.#: <br /> HAZARDOUS SUBSTANCE STORED&G.A.S.# <br /> All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> I D UBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER Q 95 UNKNOWN <br /> A.TYPE OF 99 OTHER <br /> SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT <br /> STEEUIRON F-] 2 STAINLESS STEEL F] 3 FIBERGLASS 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE E] 6 POLYVINYLCHLORIDE E] 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> fl 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN El 99 OTHER <br /> 1 RUBBER LINED 2 A LINING 3 EPDXY LINING [—] 4 PHENOLIC LINING <br /> C. INTERIOR El F-15 GLASS LINING 6 UNLINED El 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 1 METHANOL? YES [:] NO 99 OTHER <br /> LD.CORRosiom 01POLYETHLENEWRAP 2TARORASPHALT 3VINYLWRAP El4FIBERGLASSR€INFORCEDPLASTIC <br /> ECTION 0 5 CATHODIC PROTECTION [:] 91 NONE 95 UNKNOWN ❑ 99 OTHER <br /> IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND„ U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A CuLl SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE{PVC) A U 4 FIRERGLASS PIPE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN <br /> P S 99 OTHER <br /> Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE wAsrANKFILLEowITH <br /> S. ESTIMATED DATE LAST USE (MO/YR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN IN <br /> MATERIAL? YES L:] NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME SPRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> AGENCY# FACILITY ID# TANK ID# <br /> 71 <br /> CURRENT LOCMAPPROVED BY NA E PHONE#WITH AREA CODE <br /> .A(�CNCY FACILITY <br /> (fes f ID# IF, 5 d <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMI EXPIRATION ATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIED A RCILITYIS1TE APPLICATION, FORM `A',UNLESS AILTIRRENT FORMA' HAS BEEN FILED <br /> DATA 'PROCESSING COPY <br />