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STATE OF CALIFORNhw WATER RESOURCES CONTRC,.OIOARD FORM `BT: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INF RMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INPORMATION FOR EACH TANK. MARK ONEITEONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION E TA ' I O ONE ITEM ❑2 INTERIM PERMIT T MANENTLY CLOSED TANK ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 77 19 ypo le/l�� G/ FARM TANK-YES NO � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-So SPECIFY A. OWNERS TANK ID p e. MANUFACTURED CD C. C. YEAR INSTALLED CA) L D. TANK CAPACITY IN GALLONS: If. TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED IESEL F-13 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.# C.A.S.#: 4('- Ill. -III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED Wff I EXTERIOR LINER UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK ❑ I STEELPRON ❑2 STAINLESSSTEEL ❑3 FlBERGLA ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 AL UM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBKRUNED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 COMING LINING E35 GLASS LINING ❑6 UNLINED UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH Ion METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 V RAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION El CATHODIC 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 KNOW 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 NKNO N U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETEA U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UCWdKNOW 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 / VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ONITOR P S S GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P S ] PRESSURE TESTING P S 91 NONE P 8 5 UNKNO N P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF &WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 9 ql I o1 1 o � LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE ro pS; PERP PERMIT APPROVAL DATE PERYR EXPIRATION DATE ECK# PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT BY: al�b RMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY