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STATE OF CALIFORNI WATER RESOURCES CONTR*OARD ;. FORM `BI: UND GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE rel 8 TANK REMOVED to F If FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO •0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID M D B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS ineD C II. TANK gALfNTENTS IF(A.1),IS MARKED,CO LETE ITEM C.IF(A.1),JS NOT MARKED,y6MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOW E 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.R I C.AS.P: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO ,B,C,6 D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH D(TER RLINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3\AMINUM GIASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F-]5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ❑ 6100%METHANOL COMPATIBLE FRP MATERIAL [:]9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 9NOWN ❑ 99 OTHER C. INTERIOR F--] 1 RUBBER LINED ❑2 ALKYD LINING F-] 3 EPDXY WING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ YES NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUN BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUREA U 3 GRAVI 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 T NCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL HLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD /FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PR ARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTR NIC 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 UNKNO N P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FACILITY ID R TANK ID k = 100 1 D 17 1 CURRENT LOCAL AGE CY FACILITY ID M APPROVED BY NAME PHONE A WITH AREA CODE 3 a PERMIT NUMBER PERMIT APPROVAL DATE PER EXPIRATION DATE CHECKX PERMIT AMOUNT SURCI Am HARGE AMT. FEE CODE RECEIPTF BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED 8 ACIUTY/SRE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY