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STATE OF CALIFORPI WATER RESOURCES CONTRL_ ;OARD FORMIB': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3:35 9 I. TANK DESCRIPTION Cnuel �� .• • •. .M5 CHANGE OF INFORMATION ❑ 7PERMANENTLY ❑ 6 TEMPORARY TANK CLOSURE [L 6'TANK REMOVED _ FApM TANK -YES A. OWNERS TANK ID # — v SEL MANUFACTURED BY: Ll C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: - • ow 1 II. 4111), US NUT MARKED, COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. E]1 UNLEADED ❑ 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY E]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. #: 111• InmN%'WN*lRUCllVN MARKONEITEMONLYINBOYA.e_C.An A TYPE OF ❑ 1 DOUBLE WALLED F3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER B. ❑ I STEEL/IRON 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATTERLLL ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 MINUM ❑ 8 100% METHANOL COMPATIBLE FAP A ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 P ENOLIC LINING LINING ❑ S GLASS LINING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP �NKNOWN ❑ IS UNING MATERNAL COMPATIBLE WITH 100% METHANOL? ❑ YES ❑ NO �pTHER Ld �• D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAl10R ASPHALT 0 3 VI LWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCA F A IF ARnVF rQnl INTI 11 ¢ INnconon u.m anwu — ...— 6 1 VISUAL CHECK P S 2 INVENTIwORY RECONCIUATION P 8 3 VADOSE WELLS P S 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 L VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER SURCHARGE AMT. FEE CODE A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASSPIPE 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 DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 6 1 VISUAL CHECK P S 2 INVENTIwORY RECONCIUATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 P 8 95 UNKNOWN P 8 99 OTHER L VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE PERMIT gPPROVAL DATE IERMIT 1. ESTIMATED DATE LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE. IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # La JURISDICTION # = AGENCY # FACILITY ID # O O `�-/ I TANK ID # O CURRENT LOCAL AGENCY FACILITY IDN L 3 APPROVED BY NAME 1 PHONE N WITH MG CODE PERMIT NUMBEfl PERMIT gPPROVAL DATE IERMIT EXPIRATION PATE CHECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE gECEIPTN BY: FORM B (6-29-88) 1 MIS FVKM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FVRfill 'A', UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY CTI N t" N I"