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zfn`. WATER RESOURCES CONT BOARD STATE OF CALIFORI► -fix `1 FORM 613% UNDERGROUND STORAGE TANK PR GRAM S TANK TANK PERMIT APPLICATION INFORMATION opt, COMPLETE A SEPARATE FORM WITH THE FOLLOW IN G,91FORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED 11 5 P70-�" FARM TANK -YES ❑ NO FACILITYISITE NAME WHERE TANK IS INSTALLED: E. • 1. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN , SO SPECIFY EC, =INSTALLED B. �TANK CTURED BY: D. PACITYIN GALLONS: II. 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 E. C- ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT 0 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS PTY 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) F-1 5 HAZARDOUS El BO EM D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF C.A.S. W HAZARDOUS SUBSTANCE STORED & C.A.S. ft III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, A O A TYPE OF ❑ 1 DOUBLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER SYSTEM[Del INGLEWALLED F14 SECONDARY CONTAINMENT STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 1 RUBBER LINED [:]2 ALKYD LINING ❑ 3 EPDXY LINING C. INTERIOR LINING ❑ 5 GLASS LINING F-]6 UNLINED 100% METHANOL? ❑ YES ❑ NO ❑ IS LINING MATERIAL COMPATIBLE WITH D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL P PROTECTION F]5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 95 UNKNOWN 99 OTHER ❑ 4 STEEL CLAD MFIBERGLASS REINFORCED PLASTIC ❑ B 100% METHANOL COMPATIBLE FRP ❑ 99 OTHER ❑ 4 PHENOLIC LINING NKNOWN ❑ 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 k 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 5 UNKNOWN A U 99 OTHER A U 1 STEL/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 A U 6 CONCRETE A U 7 STEEL CLAD WIERP A U B 100%METHANOLCOMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR 5 FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p S 1 VISUAL GHECK P S 2 INVENTORY RECONCILIATION P{ E WELLS F $ , 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS `P S 91 NONE �! S 5 UNKNOWN P S 99 OTHER P S 6 PRECISION TESTING P S 7 PRESSURE TESTING �' ys VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE W CA THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY TAMC ID # Li CURRENILrCAt, AG` Y FACILITY APPROVED BY NAME y�] PHONE # WITH AREA CODE � ID # � f PERMIT NUMBER PERMIT APPROVAL DATE I PpRMIT EXPIRATION DATE CHECK # PERMIT AMOUNT ,SURCHARGE AMT. FEE CODE IRECEIPT # I BY: FORM B (6 -29 -BB) THIS FORM MUST BE ACCOMPANIM A FACILITYISITE PROCESSING ORCflPA% UNLESS AAI RENT FORMA' HAS BEEN FILED J