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STATE OF CALIFOR& WATER RESOURCES CONi*L BOARD FORM IBI: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION °^; COMPLETL A gEPARAIE FORM WITH THE FOLLOWING INPORMAtION FOR EACH TANK. ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT � OE OF INFORMATION ❑ /PERMANENTLY CLOSED TANK 1 "am ❑2 INiEIRM PERMIT ❑4 AMENDED PERMIT ❑0 TEMPORARY TANK CLOSURE ❑0 TANK REMOVFD G Y [FA;CfLt"/lITl NAYS YYIIERE YANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY a A. OWNERS TANKIO I „� B. MANUFACTURED BY: C. YEAR INSTALLED C_ D. TANK CAPACITY IN GALLONS: 11. TANK NTENTS IF(A.%is MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A Fj1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8, -- C. ❑ I UNLEADED ❑2 LEADED ❑` 9 DIESEL F]3 CHEMICAL PRODUCT ❑4 00. 0-f-PRODUCT ❑4 OASAHOL ❑ 5 JET FUEL ❑0 AVIATION GAS ❑5 HAZAM3DU3 RO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ /METHANOL ❑99 OTHER(DESCRIRE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A CA.S.E CA.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S,C.A 1) A TYPE OF ❑ I WADm ❑3 SINGLE WALLED WITH EX M00 LIKA ❑95 UNKNOWN SYSTEM �❑22 SNGIEWAUID ❑4 SECONDARY CONTAROAENT ❑99 OTHER IJ I SfEELIRON 02 STAINLESS STEEL 0 3 FIBERGLASS ❑1 STEEL CUD W/RRDIOUSS REINFORCED PLASTIC S.TANK CRETE POLYVINYL DLORDE 2 ALUMINUM MATERIAL ❑5 CON ❑0 POLYVI ❑ ❑01011W METHANOL COMPATIBLE f11P ❑9 BIIDN2E ❑ 10 GALYAMZED SIEEL 95 UNKNOWN ❑99 OTHER G INTERIOR ❑ I RIBBE ts" ❑2 NNO ❑3 EPDXY LINING ❑1 PHENOIK LMNG LINING ❑s qAM LINING � S UNLINED ❑95 UNIMOWN ❑B UNNG LATERAL COMPATIBLE WITH 100%MMNOLT YES 0 N 990THER O.CORROSION ❑ 1 RXnIMENE*PAP OR ASPHALT 3 VRM WRAP 4 FIBERGLASS REINFORCED PLASTIC MOTECTIOK ❑5 CARDDIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A LA I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U BI NONE A U( 5 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 131 ALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A U SUNKNOW A U 99 OTHER A 3L15TEEki4" A U 2 STAINLESS 97EEL A U 3 POLYVINYL CHLORIDE)PVC) A U 4 FIREnGIAS PI ` A U 91 NONE C.MATO W. A U S ALUMINUM A U S CONCRETE A U / 9TEEL CUD W/FRP A U B RUBE METHANOL COMPATIBLE FRP A U 0 GALVANIZEb STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE 0 FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S IVWAL CHECH P S 2 INVENTORY RECONCILIATION F S 3VADOSE WELLS P 9 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS S S PNECIOIONTESTING P S I PRESSURE TESTING P #__SI NN NOE` P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES U NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TI1E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'9 NAME(PRINTED S SIONATURE) DATE LOCAL AGENCY US ONLY CO�J-1J JURISDICTION AGENCY 1 FACILITY ID 1 TANK ID 0 = El L, I C E=, Ci , CGIIRENT LOCAL AGENCY FACILITY ID 1 APPROYED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE -- CHECK E RM AMOUNt SURCHARGE AMT. FEE CODE RECEIPT I BY: rorlMBrosFeel TNIIFORMNMI EEAtkGM►AREGSTAFACKIPF/SITEAPPLICAflON, FORM'A',UNLESSACURRENT FORM'A' HASBEENFILEO nAf• n