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5 1 Al t Ur CALIFUH A WATER RESOURCES CON� <br />FORM'S'; U RGROUND STORAGE TANK PROL BOARD <br />GRAM <br />TANK �< TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH <br />MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT <br />ONE ITEM �21NTERIM PERMIT 5 CHANGE OF INFORMATION <br />4 AMENDEDPERMIT 6 TEMPORARY TANK CLOSURE <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: <br />_-1 -- Lai; <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN So <br />A. OWNERS TANK 10 a SPECIFY - <br />U.YEARINSTALLED I C) B. MANUFACTURED BY: �Y <br />K.j,: '. <br />FARM TANK - YES <br />(a <br />II. TANK CANTENTS <br />DAN K CAPACITY IN GALLONS: <br />MARK 014E ITEM ONLY IN BOK A, B, C, a D <br />IS MARKED, COMPLETE ITEM C. IF (A. , i <br />A I MOTOR VEHICLE FUEL 2 PETROLEUM <br />OT MARKED, COMPLL TE ITEM0. <br />3 CHEMICAL PRODUCT 4 OIL <br />5 HAZARDOUS BO <br />1B / <br />�J PRODUCT <br />C. ❑ I UNLEADED <br />4 GASAHOL <br />E] 2 LEADED 3 DIESEL <br />5 JET FUEL <br />EMPTY 95 UNKNOWN <br />0. NOT MOTOR VEHICLE FUEL, ENTER NAME OF <br />2 WASTE <br />7 METHANOL <br />GAS <br />IF <br />99 OTHER (DESCRIBE <br />❑IN ITEM ID BELOW) <br />HAZARDOUS SUBSTANCE STA C.A.S. Y <br />ORED <br />C. INTERIOR I141EIUNED 2ALXYDUNINO <br />El EPDXY <br />99 OTHER <br />LINING <br />LINING ❑ 5 GLASS LINING <br />©6 UNLINED <br />III. TANK CONSTRUCTION <br />C.A.S. a: <br />MARK 014E ITEM ONLY IN BOK A, B, C, a D <br />A TYPE OF ❑ 1 DOUBLE WAULD 3 SMILE WALLED MTN EXTERIOR LINEN <br />SYSTEM 2 SINGLEWALLED 4 SECONDARY CONTAINMENT <br />❑ F' UNKNOWN <br />8. TANK ❑ I STEEURON 2 STAINLESS STEEL 3 FIBERGLASS <br />El 99 OTHER <br />MATERIAL S CONCRETE 6 FOLYWNYL CHLONDE E] 7 ALUMINUM <br />1 STEEL CIADW/FIBERGLASS REINFORCED PLASTIC <br />9 BRONZE 10 GALVANIZED STEEL ED95 UNKNOWN <br />Y 100%MM"OL COMPATIBLE FRP <br />C. INTERIOR I141EIUNED 2ALXYDUNINO <br />El EPDXY <br />99 OTHER <br />LINING <br />LINING ❑ 5 GLASS LINING <br />©6 UNLINED <br />/ pHENOUC LINING <br />LS LINING MATERIAL COMPATIBLE WITH IOBK METHANOL? YES E] NO <br />95 UNKNOWN <br />E] 99 OTHER <br />D. CORROSION ❑ I POLYETIUNEWRAP 2 TAR ON ASPHALT 3 VINYL <br />WRAP <br />PROTECTION 0 5 CATHODIC PROTECTION 91 NONE <br />❑ 4 FIBERGLASS REINFORCED PLASTIC <br />ED 95 UNKNOWN <br />[] 99 OTHER <br />IV. PIPING INFORMATION <br />CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />A SYSTEM TYPE <br />A U I SUCTION <br />B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U <br />95 UNKNOWN A U 99 OTHER <br />A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE <br />A U I STEEL/IRON A A U 95 UNKNOWN <br />U 2 STAINLESS STEEL A U 99 OTHER <br />C. MATERIAL U S ALUMINUM A U 3 POLWINYL CHL ORIDE LPVCI A U 4 FIBERGLASS PIPE <br />A U 6 CONCRETE <br />A <br />A U 7 STEEL CLAD W/FRP U 91 NONE <br />A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U B 100% METHANOL COMPATIBLE FRP <br />A U 99 OTHER <br />V. LEAK DETECTION SYSTEM <br />CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK <br />P S <br />1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION <br />DETECTION SYSTEM MUST BE CIRCLED. <br />P 8 3 VADOSE WELLS P 8 <br />P S 6 PRECISION TESTING P g 7 PRESSURETESTING P 8 91 NONE <br />4 ELECTRONIC MONITOR P g 5 GROUNDWATER MONITORING <br />P 8 <br />VI. INFORMATION ON TANK PERMANENTLY <br />95 UNKNOWN WELLS <br />P g 99 OTHER-� <br />1. ESTIMATED CLOSED IN PLACE <br />DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF <br />SUBSTANCE REMAINING IN <br />3. WAS TANK FILLED WITH <br />GALLONS INERT MATERIAL? YES <br />THIS FORM HAS BEEN COMPLETED UNDER PfNALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND E3ECT. NO <br />APPLICANT'S NAME (PRINTED S SIGNAI ONE) <br />DATE <br />CAL AGENCY USE ONLY <br />COUNTY # JURISDICTION 0 l <br />AOENCY Y FACILITY ID Y <br />j G �� TANK ID Y <br />T7-71 <br />RENT LOCAL AGENCY FACILITY ID # / ET/ <br />PERMIT <br />PERMIT <br />CHECK# 7PERYITAYOUNT <br />BURCNARGE AMT. <br />FORM B W29-66) THIS FORM MUST BE <br />APPROVED BY NAME <br />PHONE # WITH AREA CODE <br />DATE PERMIT EI(PIRATION DATE <br />FEE CODE 7 <br />IPT/ By. <br />r V HM 'A', UNLESS A CURRENT FONY'A' MAg BEEN p <br />DATA PROCESSING Copy <br />