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AI_C UIF CALIFOR AW WATER RESOURCES CONJO BOARD FORM `Q';. . UINIRGROUND STORAGE TA NK GRAM . TANK TANKPERMIT APPLICATION I SiOII+! ORMATIQN =yea MALETE A SEPARATE FORM WITH THE FOLLOWNFORMAY ION FOR EACH TANK. .'; EFA K ONLY' ❑1 NEW PERMIT ❑3 RENEWAL PERMIT u E ITEM 2 INTERIM PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY C SEI)TANK ❑4 AMENDED PERMIT fi TEMPORARY TANK CLOSURE TY/SITE NAME WHERE TANK IS INSTALLED: ❑B TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN'So SPECIFY S FARM TANK-YES A. OWNERS TANK Ip p B. MANUFACTURED BY: A. YEAR INSTALLED If. TANK D. TANK CAPACITY IN GALLONS: C NTENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,C PLETE ITEM 0. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM �rl C. 1 UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT �4 OIL ❑5 HAZARDOUS EMPTY PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ ❑95 UNKNOWN 2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) LF NOT MOTOR VEHICLE FUEL,ENTER NAME OF AZARDOUS SUBSTANCE STORED&CA.S.N lI1. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,B,C,&D C.A.S. rAF ❑I DOUBLE WALLED ❑3 SINGLE WALLED MTN EXTERIOR UNER 2 SINGLE WALLED ❑95 UNKNOWN ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ T STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REI ------- MATERIAL PLASTIC L ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B)W411 METHANOL COMPATIBLE RTP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER R ❑ I RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING 4 PHENOUC LINING ❑5 GLASSLINING ❑6 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑NO ❑99 OTHER ION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC ION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN 99 OTHER !V. PIPING INFORMATION CIRCLE A IFA13OVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE rQUATERIAL TYPE A U 1 SUCTION A U 2 PRESSURE CONSTRUCTION A U I 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 A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 6 100%METHANOL COMPATIBLE FRP 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 6 1 YISURL CHECK P 6 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P $ 6 PREClSIDN TESTINQ P S 7 PRESSURE TESTING P S 91 NONE VI.11 INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 95 UNKNOWN P 9 s9 OTHER 1.ESTIMATED PATE LAST USED EMO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3 WAS TANK FILU:U WITH GALLONa !NEAT MATERIAL? ❑YESNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO ,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) WLEDGE DATE LOCAL AGENCY USE ONLY COUNTY#Ex , t JURISDICTION# AGENCY# FACILITY ID a TANK IO# CURRENT LOCAL AGENCY FACILI MD a 21= APPROVED BY NAME PHONE/WITH AREA CODE PERMIT NUMBER / PERMIT APPROVAL DATE PERMIT EIIPIRATION DATE CHECKS PERMITAMOUNT6U9 RCHARI3E AML FEE CODE RECEIPT# 8Y: FORM A(6-29.89) THIS FORM MUST BE ACCOMPANIE :A FACILITY/SITE APPLICATION, FORM $A 1fNLESS A C RREYT Cnhu�a� ^A � ��___ ! •n R��-.�..