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STATE OF CALIFOR <br /> WATER RESOURCES CONT BOARD <br /> FORM UNDERGROUND STORAGE TANK PRGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION t_�; <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Y <br /> MARK ONLY i NEW PERMIT <br /> 3 RENEWAL PERMIT - <br /> ONE ITEM 0 2 INTERIM PERMIT5 CHANGE OF INFORMATION 1 <br /> 4 AMENDED PERMIT �Z PERMANENTLY CL K <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED. 06 TEMPORARY TANK CLOSURE <br /> 0 8 TANK REMOVED <br /> I. TANK DESCRIPTION COMPLETE ALL!TENS-!F UNKNOWN- FARM TANK-YES 0 NO <br /> A. OWNERS TANK ID q SO SPECIFY <br /> C. YEAR INSTALLED B. MANUFACTURED BY: S <br /> D. TANK <br /> TY IN GALLONS: <br /> 11, TAN ONTENTS IF(A.1 IS MARKED,COMPLETE ITEM C.IF(A-1),IS NOT MARKED,I COMPLETE ITEM 0. <br /> �� <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM <br /> 03 CHEMICAL PRODUCT 0 4 OdL B C. 0 1 UNLEADED 0 2 LEADED��� 0 3 DIESEL <br /> 0 5 HAZARDOUS LP�f ' PRODUCT 04 GASAHOL 0 5 JET FUEL <br /> 0 B0 EMPTY 0 95 UNKNOWN 0 2 WASTE 7 METHANOL 0 6 AVIATION GAS <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 0 �9 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.it <br /> III. TANK CONSTRUCTION MARK QNE ITEM ON �L - C.A.S a: <br /> LYINBOXA,B,C,BD <br /> A. TYPE OF 1 DOUBLE WALLED <br /> SYSTEM 0 3 SINGLE WALLED WITH EXTERIOR LINER 0 95 UNKNOWN <br /> 0 2 SINGLEWALLEO <br /> 0 4 SECONDARY CONTAINMENT <br /> 0 99 OTHER <br /> 1 STEELPRON 0 2 STAINLESS STEEL <br /> B. TANK 0 3 I_UMINLASS 0 4 STEEL C AD WIFIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 0 5 CONCRETE 0 6 POLYVINYL CHLORIDE 7 ALUMINUM <br /> 0 9 BRONZE 0 0 8 190%METHANOL COMPATIBLE FRP <br /> 0 10 GALVANIZED STEEL 0 95 UNKNOWN <br /> 0 99 OTHER <br /> C. INTERIOR El 1 RUBBER LINED 0 2 ALKYD LINING <br /> LINING 0 5 GLASS LINING 03 EPDXY LINING 0 4 PHENOLIC LINING <br /> 6 UNLINED <br /> 0 IS UN1NG MATERIAL COMPAT&E WITH 1007%METHANOL? 0 95 UNKNOWN <br /> El YES E] Na le'49 OTHER <br /> D. CORROSION 0 1 POL ETHLENE WRAP0 2 TAR OR ASPHALT <br /> PROTECTION 0 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> CATHODIC PROTECTION 0 91 NONE 11 <br /> 0 95 UNKNOWN 0 99 OTHER <br /> IV. PIPING INFORMA ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A sucTlpN <br /> A U 2 PRESSURE A U 3 GRAVITY <br /> B. CONSTRUCTION A SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9i NONE ER <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 7 STEEL CLAD WlFRP A 8 100%METHANOL CDMPATPBLE FRP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSp S 4 ELECTRONIC MONITOR <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 5 91 NONE S 5 GROUNDWATER MONITORING WELLS <br /> p 95 UNKNOWN P S 99 OTHER <br /> VI, INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMAT D DATE LAST USED(MO/YR) 2. ESTIMATED OU. I NI -Y OF <br /> SUBSTANC RE Al ING IN 3. WAS NK FILLED WITH <br /> GALLONS I E TEMAL? 0 YES F NO <br /> THIS ORM HAS BEEN COMPLETED UNDER PENAL TY OF P RJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> AGENCY# FACILITY ID# <br /> aHlTANK ID# <br /> 00 9 7 alila <br /> CURRENT LOCAL AGENCY FACILITY ID k <br /> APPROVED BY NAM / <br /> f (� PHONE k WITH AREA CODE <br /> PERMIT NUMBER UX' <br /> PERMIT APPROVAL DATE PERM? EXPIRATION DATE <br /> CHECK k PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE <br /> RECEIPT k BYr <br /> FORM B(6-29-6a) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />