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STAIT OF CALIFORNWATER-RESOURCES CONTR OARD FORM IBI: UND GROUND STORAGE TANK PRAM :•:, TANK PERMIT APPLICATION INFORMATION TANK - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATInN FnIQ Peru rwuv MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLK ONE ITEM ❑ 2 INTERIM PERMIT ❑-4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �TA�K REMOVED 0'q FACILITY/SITE NAME WHERE TANK IS INSTALLED: u7 d� FARM TANK -YES ❑ Nnn Uc.1L,nlr 1 ION COMPLETE ALL ITEMS -IF UNKNOWN - $O SPECIFY A. OWNERS TANK IDP B. MANUFACTURED BY C. YEAR INSTALLED D TANK CAPACITY IN GALLONS: .r IA. q, IO MANRLU, UUMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ i UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. N C.A.S. N: -•••-�...... ,.,,. nunc ncM unu In BUA A, B, C,AD A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 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 ❑ fi POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100% METHANOL COMPATIBLE FRP BY: ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED El2 ALKYD LINING 1:13 EPDXY LINING El4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOLY ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2TAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION r.IFrI F A ¢ A.n„. o V. VI. A. SYSTEM 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 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 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER ccnn vo I GL.I IUIY *Tb I CM CIRCLE P FOR PRIMARY. OR S FORRFCnMnARV a P S 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER ,... V.1..If1IIVIV vI. IAnn rcnWIAlNtNILY CLOSED IN PLACE I. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES E]NO TNIC F/IOIIA uAc Drcn, rnun, rr�.. • •. •.. �.. .._.... _ . __ — - - ---' - - �•-•• -� • �•� �•�_., ro,,L 17 yr rcrc✓UHY, ,RAIU 10 I HE BEST OF MY KNOWLEDGE, IS TRUE AND C( APPLICANT'S NAME (PRINTED 8 SIGNATURE) DATE LOCAL Al RRECT COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # O JC LID, FACILITY IDN ^ I F )r I APPROV BY NAM r' _ PHONE N WIT” AREA CODE n 7 Cm t -- l Y . BER L PER M[TAP PROYAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SUR CHARGE AMT. FEE CODE RECEIPTN BY: FORMB(6-29-881 THIS FORM MUST RF ACCRMDAY .ce ....... --- DAPROCESCO TA PROCESSING COPY .., • ....,..L.1111unncm rUHM'A' NASBEENFILED z 10 CA) N Cn