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STATE OF CALIFORNIf WATER RESOURCES CONTRQr`QARD�g� FORM `BRG ': UNDERGROUND STORAGE TANK PRO� 0 iAM 12((4 TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _a MARK ONLYEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED TANK ONE ITEM '1'2"14N TERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO-1�� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1 A. OWNERS TANK ID# (� -�--2� B. MANUFACTURED BY: LLN C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS'. w II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ISQI MOTOR VEHICLE FUEL F-12 PETROLEUM B. C. ❑ 1 UNLEADED Ll2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 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.# C.A.S.W MI. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,A D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH E%FERIOR LINER ❑95 UNKNOWN SYSTEM srl SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEUPON ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC R.TANK ol MATERIAL F-15 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 1DD%METHANOL COMPATIBLE FOP ❑9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR LINING ❑ 5 GU55 LINING ><6 UNLINED ❑95 UNKNOWN ❑ 15 LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP �2 TAR OR ASPHALT ❑3 VINYLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A Wl SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 19 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U S 100%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 S 1VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE 6)$ 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED CITE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WASTANK FILLED WITH SUBSTANCE REMAINING IN L/ GALLONS INERT MATERIAL? RYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 1010h 1 5 38Oo OS CURRENT LOCAL AGENCY FACILITY IDY E ^� PHONE#WITH AREA CODE Z ((��( PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTk BY: FORM B(34-SB) THIS FORM MUST BE ACCOMPANIEu BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED i