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STATE OF CALIFORNit WATER RESOURCES CONTR•BOARD <br /> FORM IBI: 'UNDERGROUND STORAGE TANK PROGRAM <br /> TANK / ,TANK PERMIT APPLICATION INFORMATION <br /> coFAPL..A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT Fj 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Lj 7 PERMANENTLY CLOSED TANK I <br /> ONE ITEM 2 INTERIM PERMIT 0 /AMENDED PERMIT E]e TEMPORARY TANK CLOSURE E:]B TANK REMOVED Oq <br /> CTI <br /> FACR.flY/BYT!NAME WHERE TANK IB INSTALLED: 6"c Y /t,s FARM TANK-YES NO U N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—80 SPECIFY A <br /> N <br /> A. OWNERS TANK 101 -yl / B. MANUFACTURED BY: <br /> C. YEAR INSTALLED cam//c_— D. TANK CAPACITY IN GALLONS: o2 Cjp <br /> 11. TANK C TENTS IP(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. b 1 MOTORVEHICLEFUEL Ej 2 PETROLEUMB. / C. O t UNLEADED LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT M/OR pf CT ❑ /GASAHOL Ej 5 JET FUEL B AVIATION OAS <br /> U]5 HAMRC" El SO EMPTY 095 UNKNOWN 0 2 WASTE O 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,SELOWI <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOU9 SUBSTANCE STORED 6 CA.S.1 C.A.S.9: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.E,C.A D <br /> A TYPE OF ❑jD66811 WAILED F-1 3 SMLE WALLED VAIN EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 0 F SINGLE WALLED I SECONDARY CONTAINMENT 99 DRIER <br /> 1 STEEL/EON 2 STAINLESS STEEL F]3 FIBERGLASS Ej1 MEL CUD W/RBEnGUSS REINFORCED PLASTIC <br /> B.TANK <br /> MMATERIAL0 S GORGETS F]e POLYVINYL CHLORIDE Ej7 ALUMINUM [:]e IM%METHANOLOOMPARBLEHRP <br /> E]9 BRONZE 10 GALVANIZED STEEL 0.95 UNKNOWN ❑ 99 OTHER <br /> C.INTERIOR n 1 RIBBDILNED F]2 AMOLININO 3 EPDXY LINING ❑1 PHENOLDLR3NG <br /> Lm" ❑S GAS9UNNR D [:j 95 UNKNOWN <br /> Ej 19 LINRAI MAtMk COMPAR9lf WITH 100W METHANDL7 EJ YES 0 NO Ej 99 OTHER <br /> D.CORROSION ❑ I POLYERIENE WRAP 0 2T ASPHALT 3 VINYLWRAP Ej/Remu9s REINFOIDED PU9TD <br /> PROTECTION 5 GRIODIC PID1EC7gN 91 NONEEl 95 UNKNOWN 99 O7HER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TRIS A U I STICTION A U 2 PRESSURE A U 3 GRAVITY A U911 NOIP., A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U I SINGLE WALLED, A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 1 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A LA I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A LA I FIBERGLASS PIPE A 91 NONE <br /> C.MATERIAL U e ALUMINUM A U e CONCRETE A U 7 STEEL CLAD W/FRP A U 9 109%METHANOL COMPA7I <br /> A U 9 OALVAMZED 91EEL A U 95 UNKNOWN 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 IW9UALCHECIK P I 1 INVEWORYBECONCILIATION P ! 3VADOSEWELLS P 1 / ELECTRONICMONITOR P 1 5 OOOUNDWAIERMONIIORINOWFLLS <br /> P / e PRECHNON TESTING P I 1 PRESSUMTESTING - E 91 NONE'I P / 95 UNKNOWN P 1 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLON! INERT MATERIAL? YES [:]NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY I JURISDICTION I AGENCY/ FACILITY ID I TANK IO N <br /> ED <br /> = D c 4 D / [.c/ G c-) / <br /> CUIIREMY LOCAL A000 FACILITY ID 1 p APPROVED RY NAME PHONE I WITH AREA CODE <br /> PERMIT MUNI IR PERMIT APPROVAL DAT! PERMIT EXPIRATION DATE <br /> 'HlCR/ PERMIT AMOUNT UR O!AMT. <br /> FEE <br /> CODE C BY: <br /> rom.1 R(e n am THISFORM MUST BE ACCOWANMD BY A FACILITY/BITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br />