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a z " ',STATE OFICALIFORNOWATER RESOURCES CONTR OARo FOR °: UNDERGROUND TANK PROFURAM o , TANK PERMIT APPLICATION INFORMATION TANK m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Fa'" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ® 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL K 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED FACILITY /SITE NAME WHERE TANK IS INSTALLED: ? 5 FARM TANK - YES ❑ NO7 1, I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN — SO SPECIFY 3 161-7 Ilf It'g 00 11. TANK CONTENTS IF (AA), IS MARKED, COMPLETE ITEM C. IF (.1), IS NOT MARKED, COMPLETE ITEM D. A. OWNERS TANK B. MANUFACTURED BY: C. 1 UNLEADED 2 LEADED ❑ 3 DIESEL C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: � 4 GASAHOL 5 JET FUEL ❑ 6 AVIATION GAS A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM 2. ESTIMATED QUANTITY OF C. 1 UNLEADED 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL VB. 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. #: I1.' T CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, , C, D A TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B. TANK ® 5 CONCRETE ® 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE FRP MATERIAL ® 9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ® 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ® 2 ALKYD LINING 3 EPDXY LINING V95 HENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES ❑ NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPINGI F I CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AR 95 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 A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK T CTI YQST CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 64 1 P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S I VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION TANK PERMANENTLY CLOS IN PLACE THIS FORM HAS BEEN 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 # TANID CURRENT LOCAL AGENCY FACILITY ID # ' ROVED BY NAME PHONE # WITH PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK # PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT # BY FORM B (6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, 'FOR `', UNLESS A RRENT fORM `A' HAS BEEN FILED DATA,iPROCESSING 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ®NO GALLONS