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STATE OF CALIFORNWATER RESOURCES CONTR OARDRAM FORM W: UND GROUND STORAGE T RAGE TANK PR - T ; TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.,Fad P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EJ<CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED r FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0o FARM TANK - YES ❑ NO 'ANK DESCRIPTION COMPLFTF ALI ITFYS - IF IIMKMOWM _ SA SDFCICV 61 1 A. OWNERS TANK ID # B. MANUFACTURED BY: C. YEAR INSTALLED 7 D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IV. IF (A.7), IS MAHREU, UUMPLETE ITEM G. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. -11 A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B.�PRODUCT C. ❑ 1 UNLEADED EADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ^fit ❑ 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. #: x111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D 1` A. TYPE OF ❑ 1 DO E WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SIN WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 99 OTHER El 1 STEEL/IRON F-12 STAINLESS STEEL F-]3 FIBERGLASS F-]4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL F-15 CONCRETE ❑ 6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑ B 100% METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER 2 STAINLESS STEEL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING P C LINING C. INTERIOR LINING ❑ 5 GLASS LINING ❑ 6 UNLINED U R�95-UNKNO'WN A IS LINING MATERIAL COMPATIBLE WITH 1 HANDL? YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER FIPINU INFQRMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH U 5 UNKNOWN A U 99 OTHER A U 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 6 CONCRETE A U 7 STEEL CLAD W1 FRP A U 8 100% METHANOL COMPATIBLE FRP � A U 9 GALVANIZED STEEL A/U 95 UNKNOWN A U 99 OTHER . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED (MP/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH TANK ID # SUBSTANCE REMAINING IN INMATERIAL? [::]YES [::]NO Iv lol - r 5to GALLONS CURRENT LOCAL AGENCY ID # THIS FORM HAS BEEk COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # FACILITY ID # TANK ID # ® IFACI`LIITTY Iv lol - r 5to [olo CURRENT LOCAL AGENCY ID # APPROVED BY NAME HONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE P RMIT EAPIRATION DAME CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANMiWA FACILITY/SITE APPLICATION, FORM *A',UNLES14pWNT FORMA' HAS BEEN FILED DATA PROCESSING COPY