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STATE OF GALIFOA WATER RESOURCES CONT ORM `B': BOARD UNC RGROUND STORAGE TANK PR GRAM ~ > A, TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. � f MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMITE]5 CHANGE OF INFORMATION ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY C K FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q 6 TEMPORARY TANK CLOSURE �'B TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- FARM TANK'YES E] NO A. OWNERS TANK 10# SO SPECIFY MANUFACTURED ED BY C. YEAR INSTALLED , <CAPACITY II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A:),IS NOT MARKED, GALLONS: �►�lJ� A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ,COMPLETE ITEM D. B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 CHEMICAL PRODUCT ❑ q OIL �' DIESEL ❑ 5 HAZARDOUS ❑8p EMPTY 1!1 ' PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE iN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.,ENTER NAME CF HAZARD11 OUS SUBSTANCE STORED&C.A,S # III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1-DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM 2 SINGLE WALLED ❑4 E]95 UNKNOWN SECONDARY CONTAINMENT F-1 99 OTHER 1 STEELNRQN ❑2 STAINLESS STEEL B. TANK ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBE MATERIAL ❑5 CONCRETE [16 POLYVINYL CHLORIDE 7 ALUMINUM E] ❑B 10096 METHRGLASS REINFORCED PLASTIC ❑ 9 BRONZE ANQL COMPATIBLE FHP ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN E]99 OTHER C. INTERIOR ,f0 1 RUBBER LINED El ALKYD LINING LINING LJ 6 UNLINED ❑3 EPDXY LINING ❑4 PHENOLIC LINING 5 GLASS LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑ ❑ 0 95 99 OTHER WN D. CORROSION ❑ i POLYETHLENEWRAP ❑2 TAR OR ASPHALT YES NO PROTECTION ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY 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 TRENCH A U A U 1 STEEL/IRON 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 2 S7AINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)-AU 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OC%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A fi)95 UNKNOWN -A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FpR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. J� P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION 3 VAOOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 5 PRECISION TESTING P 5 7 PRESSURE TESTING P S 91 NONE P S 45 UNKNOWN P S 99 OTHER Vf. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1, EST3MATED DATE&USED(MO'YR11 2. ESTIMATED DUAN-ITY OF SUBSTANCE E WN GIN 3. WAS TA K FILLED WITH GALLONS IhfRr/ A RIAL? ❑YES ❑ NO THISFORM AS BEEN COMPLETED UNDERPENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# Jaa] URISDICTION# AGENCY FACILITY ID# TANK ID# CURRENT LOCAL AGENCY I AGILITY ID# D o / ' � I2EE��j of I / ss APPROVED BY NAME�I -41 PHONE#WITH AREA CODE PERMIT NUMBER l PERMIT APPROVAL DATE PERMIT EX IRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. AmokFEE CODE RECEIPT# BY: FORM B(6-29$8) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM `A',UNLESS A ENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY -/