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STATE OF CALIFORN* WATER RESOURCES CONTRSBOARD QO FORMIBI: UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION G�COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS NK ONE ITEM ❑2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE //,^, ❑B TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q� 3 3 ,� l,/d. FARM TANK-YES❑ NO �• B •� I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-80 SPECIFY a A. OWNERS TANK ID 6 IB. MANUFACTURED BY: (/ cn C. YEAR INSTALLED ID. TANK CAPACITY IN GALLONS: G II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. CA A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ B9 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.9 C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.8 D A.TYPE OF ❑ 1DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B TANK MATERIAL ❑5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E]8 190%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBERUNED ❑2 ALKYD UNING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑ 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IID%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TM OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 CHI A U 91 NONE A U 95 UNKNOWN A U 99 O1 HER 0. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINCG TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/NON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FHP A U B 199%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. P 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIAI ION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONO OH P 8 5 GROUND WAl ER MONITORING WELLS P S..6 PRECISION TESTING P 6 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI.1 II'N----FORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTI MAI ED DAT E LAST USI 0(MO/YfR T 2 ESTIMAI ED OUANTITY OF 3.WAS TANK FILLED WITH SUBS I ANCE REMAINING IN INUIT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLIGANI'9 NAME(PRIM?EU 8 SIGNAL UHL) DAI E I LOCAL AGENCY USE ONLY COUNTY M JURISDICTION 8 AGENCY 8 FACILITY ID 8 TANK ID B 3 � = �] Lod I I I1� � I i o v CURRENT LOCAL AGENCYF LITY IDM APPROVED BY NAPE PHONE/WITH AREA CODE IBES-fp" PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 1 PERMIT AMOUNT SURCHARGE AMT. FEE CODERECEIPT 1 BY: /' / Am 1 I GBM B 15-29-891 THIS FORM MUST BE ACCOMPANIT BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED// DATA PROCESSING COPY