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" STATE OF CALIFORNIA WATER RESOURCES.CONTROL BOARD <br /> FORM 113 - ' UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> ` AN COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. '"'.�•�'' <br /> " MARK ONLY ❑ I NEW PERMIT. ;❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM' ❑-2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK.CLOSURE ❑8 TANK REMOVED <br /> `a 'FACILITYISITE NAME WHERE TANK IS INSTALLED: fARM TANK-YES E] NO I y <br /> "I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECT +jam <br /> 'A.'OWNERS TANK IDN. B. MANUFACTURED BY: <br /> C. YEAR INSTALLED / D..TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A-1),Is MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL [:].2P OLEUM ; " B - C. El1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL- <br /> ❑3 CHEMICAL PRODUCT OIL,. :' ❑ 1.PRO CT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ;❑ 80 EMPTY ❑95"UNKNOWN ASTE .: ❑"7 METHANOL OTHER(DESCMBE"IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF" <br /> HAZARDOUS SUBSTANCE STORED d C.A.S.N C.A.S.N' ' . <br /> .v� <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,B.C.A o <br />` A TYPE OF ❑ 1.DOUBLE WALLED ❑.3 SIN�Wl� RIO ER. NKNOWN <br /> SYSTEM 2"SINGLE WALLED O 99 OTHER <br /> 1 STEELIIRON ' .: 3 FIBERGLASS " ❑4 STEEL CLAD WIFIBERGLASSREINFORCEDPLASTIC <br /> ❑. <br /> B.TANK '� ❑5 6 POL NYLCHLORIDE [�7 AL NUM ❑.6 100%METHANOL COMPATIBLE FRP ' <br /> MATERIAL- <br /> ❑ 9 BRONZE ❑ lO GALVANIZED STEEL UNKNOWN 99 OTHER <br /> i <br /> RUBBER UNEU C].2 AMD LINING:: ❑ 3 EPDXY LINING ❑4 PHEN LINING ; <br /> C INTERIOR S GLASS ❑6 UNUNEO UNKNOWN <br /> LININ_G ❑ <br /> IS LINING MATERIAL COMPATIBLE WITH 10096 MEf"OL?. '.' ❑YES ❑ NO ❑99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 7AR OR ASPHALT'. ❑3 VI ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑9t NONE UNKNOWN' ❑99 OTHER <br /> V. PIPING INFORMATION 'CIRCLE: A IF.ABOVE GROUND, U IF UNDELIND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER " <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U .2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEELl.IRON , A.U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE' A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A,U 7 STEEL CLAD W/FRP :A U;6 100%METHANOL COMPATIBLE FRP <br /> i A U 9 GALVANIZED STEEL A UNKNOWN A V 99 OTHER <br /> 1" V. LEAK DETECTION SYSTEM, CIRCLE.P'FOR PRIMARY,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1 VISUAL CHECK :6r 6 2 INVENTORY RECONCILIATION P S 3,VADOSE WELLS P S 4 ELECTRONIC MONITOR' P 8, 5 GROUND WATER MONITORING WELLS <br /> P r 6 PRECISION TESTING P S 7 PRESSURE TESTING P 6 91 NONE P- 6 95 UNKNOWN - P 8 99 OTHER <br /> VL INFORMATION ON TANK PERMANENTLY'CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED7/Y ) T 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN "" INERT MATERIAL? " •.❑YES ❑ NO <br /> GAL <br /> LONS <br /> jo <br /> ..:t'• <br /> THIS FORM HAS BE COMPLETED UNDER PENALTY OF PERJURY,AND TO.THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT.' <br /> APPLICANT'S NAME{PRINTED 3 SIGNATURE} _, DATE.. <br /> LOCAL AGENCY USE ONLY <br /> AGENCYA TANK ID A <br /> COUNTYA 'JURISDICTION <br /> .010, El <br /> v <br /> CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY AME PHONE 1 WITH AREA CODE <br /> - PFBMIT NUMBER - PERMIT APPROVAL OATS P MIT EXPIRA N DATE <br /> CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE ^ECEIPT BY: <br /> FORM s(6.29-88).'THIS FORM MUST BE ACCOMPANIED>3Y A FACILITY1SIlE APPLICATION, FORM A,UNLESS A CO RENT FORMA' HAS BEEN FILED <br />