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STATE OF CALIFORNIA WATER RESOURCES CONTRO ARD ... '��'"� UNDE ROUND STORAGE TANK PRO AM FORM 'S': ( ° ti mo TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC FI TANK. 10 ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY C 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑B TANK REMOVED / MARK ONLY F-1 ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE W ONE ITEM ❑ 2 INTERIM PERMIT G} FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: S I. TANK DESCRIPTION C MPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A B. MANUFACTURED BY: A. OWNERS TANK IDR D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MC' UNLEAOEDE ITEM z - LEADED ❑3 DIESEL a. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM PRODUCT ❑4 GABAHOL ❑5 J FUEL ❑6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT OIL 7 METHANOL 9 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF a 0 1 L C.A.S.R: HAZARDOUS SUBSTANCE STORED&C.A.S.R Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.■D ❑ 3 SINGLE WALLEDWITH EXTERIOR LINER �95 UNKNOWN A TYPE OF 1�000SLEWALLED 99 OTHER SYSTEM e2 SINGLEWAU ED ❑4 SECONDARY CONTAINMENT ❑ ❑ 1 STEELIIRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLADW/FIBERGLASSREINFORCEO PLASTIC B.TANKF] 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 UMINUM ❑610096METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL LK 95 UNKNOWN ❑99 OTHER ❑ I RUBBER UNED ❑2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC UNKNOWN LINING C. INTERIOR F-15 GLASS LINING ❑6 UNLINEDM95 _ LINING ❑IS LINING MATERIAL COMPATIBLE WITH 1009h METHANOL? ❑YES El NO 0 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2TAR OR ASPHALT NYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 0 91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPPLICABLE NO E A U 95 UNKNOWN A u 99 OTHER ESYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY ffffffSSALLED A U 2 DOUBLE W=NH H A U 91 NONE A U 95 UNKNOWN A U 99 OTHER BERGLASS PIPE A NY ON A U 2 STAINLESS /ORP E(PVC) A U R FI00%METHANOI COMPAUIBEFRpNE UM A U 6 CONCRETIZED STEEL A U 95 UNKNOW V. K DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING LNG P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑NO 1. ESTIMATED DATE LAST USED MO YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID R TANK ID N COUNTY M JURISDICTION N AGE O ® � 07 Z 6 a � APPROVED BY NAME PRONE N WITK AREA CODE CURRENT LOCAL AGENCY FACILITY Pr �O� PERMIT NUMBER ,Y, PERMITAPPROVAL DATE PERMIT EXPIRATION DATE L�/ / CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY V_ FORMB(6-29-88) THIS FORM MUSTBEACCOMPANIED BY A FACILITYPORM y'UNLESS A URRENT FORMA' HAS BEEN FILED DATAPROCESSING