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WATER RESOURCES CONTRO ARD STATE OF CALIFORNIA AM Qp �g�: UNDE ROUND STORAGE TANK PO NFORM NFORTANK TANK PERMIT APPLICATION I COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 5 CHANGE OF INFORMATION [1]7 PERMANENTLY CLOSED TANK 1 NEW PERMIT ❑3 RENEWAL PERMIT F.B'FANK REMOVED MARK ONLY ❑ ❑4 AMENDED PER ❑ 6 TEMPORARY TANK CLOSURE uu ONE ITEM F-12 INTERIM PERMIT FARM TANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1-f') I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ANUFACTUREDBY: !ti A. OWNERS TANKID# �� D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED y IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),ISNOT MCRKE❑D COMEPALDEEE ITEM 2 LEADED ❑3 DIESEL B. 6 AVIATION GAS A. ❑ 1 MOTOR VEHICLE FUEL El PETROLEUM PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ F-1 3 CHEMICAL PRODUCT FOIL Eg❑M 2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) F-15 HAZARDOUS [l 80 EMPTY ❑95 UNKNOWN ❑ p D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# T All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D IOR LINER ❑95 UNKNOWN A TYPE OF F-11 DOUBLE WALLED ❑3 SINGLEWALlEOMTH EXTER � LEWALLED ❑4 SECONDARY CONTAINMENT E]99 OTHER SYSTEM L��<SG� ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CIADWIFIBERGLASS REINFORCED PLASTIC �STEEUIRON B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑1 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP MATERS ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER UNED ❑2 A M LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR UNKNOWN LINING ❑5 GLASS LINING ❑6 UNUNEO ❑ IS LINING MATERIAL COMPATIBLE WITH HX%METHANOL? ❑YES ❑NO ❑W OTHER 1 POLYETHLENEWRAP ❑2 7 OR ASPHALT F]3 VIN ❑ 4 FIBERGLASS REINFORCED PLASTIC D. CORROSION ❑ ❑95 UNKNOWN ❑99 OTHER PROTECTION ❑5 CATHODIC PROTECTION i NONE IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A U 3 GRAVITY A U 99 OTHER A 1 SUCTION A U 2 PRESSURE p U 99 OTHER A.SYSTEM TYPE S.CONSTRUCTION A D SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN S STEEL A U ]SOEEL CLALO W/OFRP E(PVC) A U S 140%METHANOL COMPATIBLE FRP A U 1 STEEL/IRON A U 2 STAINLES C.MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 99 OTHER A U 9 GALVANIZED STEEL A U 95 UNKNOWN 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 S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 99GROUND WATER MONS WATER MON- P S B PRECISION TESTING P 8 7 PRESSURETESTING P 91 NONE- P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WASTANK FILLED WITH 2. ESTIMATED OUANTITYOF INERT MATERIAL? E]YES ❑ NO 1.ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS T IS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODATE DGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY TANKID# ON# JURISDICTION AGENCY# FACILITY ID# COUNTY# I O /'S / fQ �j O ® o PNO(NJE X W ITvH AREA CODE APPROVED BY NAM CURRENT LOCAL AGENCY FA ILITY ID# F I (24- 00 � Off` PERMIT APPROVAL DA PERMIT EXPIRATION DATE PERMIT NUMBER SURCHARGE AMT. FEE CODE pECE1PTp BY: CMECKk PERMIT AMOUNT FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED FACILITY DA A PNOCEBS NG COPYA',UNLESS A C BENT FORMA' HAS BEEN FILED