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STATE OF CALIFORIo WATER RESOURCES CONTI& BOARD S.E. FORM'S': UNDERGROUND STORAGE TANK PR GRAM A �o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANCY OF INFORMATION ❑ 7 PERMANENTLY CLO_ ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 115 U FARM TANK - YES ❑ NOE' FACILITY/SITE NAME WHERE TANK IS INSTALLED: L TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -So SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: %( C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OILF-]1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS F-] 5 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL [_99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF C.A.S. N HAZARDOUS SUBSTANCE STORED 8, C.A.S. If 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A D BLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER A TYPE OF SYSTEM SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC ❑ 6100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOLIC LINING NUNXNOWN ❑ 99 OTHER ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 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 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 C. MATERIAL A U 5 ALUMINUM AP,,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �r P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �f P S 6 PRECISION TESTING P S 7 'PRESSURE TESTING if P S NONE `. P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 8 SIGNATURE) I DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # Li I 1 2 STAINLESS STEEL ❑ 3 FIBERGLASS B. TANK �STEELIIRON ONCRETE F-] 6 POLYVINYLCHLORIDE ❑ 7 ALUVINUM MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN PERMIT NUMBER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING C. INTERIOR ❑ 5 GLASS LINING El6 UNLINED LINING ❑ IS LINING MATERIAL COMPATIBLE NTH 10096 METHANOL? ❑ YES ❑ NO D. CORROSION F-]1 POLYETHLENE WRAP ❑ 2 TAR OA ASPHALT n 3 VIS L WRAP PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 124 UNKNOWN ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC ❑ 6100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOLIC LINING NUNXNOWN ❑ 99 OTHER ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 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 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 C. MATERIAL A U 5 ALUMINUM AP,,6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �r P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �f P S 6 PRECISION TESTING P S 7 'PRESSURE TESTING if P S NONE `. P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT. APPLICANT'S NAME (PRINTED 8 SIGNATURE) I DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # Li I 1 FACILITY ID # 1010 31 A TANK ID # 101010Ld CURRENT LOCAL AGENCY F(ACICILI ID # APPROVE ME 4L� PHONE 71 WITH AREA CODE re�k O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT ✓f BY: FORM B (6-29-8S) THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A', UNLESS MRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY •®