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STATE'. PCALIF0RN1..._. WATER RESOURCES CONTRL _ OARD QO FORM 'S . UNDERGROUND STORAGE TANK PROGRAMTANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z tO MARK ONLY ' ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLgSED!01/ ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEI 0 y I� FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES -NO ❑ fV 1 O I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY S 3 >CLD A OWNERS TANK ID E B. MANUFACTURED BY: ' CD C.YEAR INSTALLED u Its. D. TANK CAPACITY IN GALLONS: (� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT E] 1 OIL ❑ I PRODUCT ❑1 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS [:] 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOWI D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.F C.A.S.E� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,i D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIROH ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 1 STEEL CUD W7FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL. 5❑ (3DIX79ETE ❑ 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑ B 1009E METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RIBBER LINED ❑2 AUOD LINING F-13 EPDXY LINING C.INTERIOR ❑/PHENOLIC LINING LINING ❑ 5 GLASS 11461C ❑6 UNLINED ❑95 UNKNOWN ElIS URNG MATERIAL COMPATIBLE NTH IOD%METHAOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHFNE WRAP ❑2 TAR INR ASPINLT ❑3 VINYL WRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 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 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 6 ALUMINUM A U B CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U B 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 B 1VISUAL CHECK P B 2 INVENTORY RECONCILIATION P B 3VAOOSE WELLS P B . ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P 1 6 PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE P t 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED GATE LAST USED(RIO/YR) 2. ESTIMATED ODANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E] YES F] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME(PRINTED SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 1 JURISDICTION E AGENCY E FACILITY ID B TANK ID E CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE 1 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE i CHECK 1 PERMIT AMOUNT IRCHARGE AMT. FEE CODE EIPT 1 BY: ♦�,` FORMB(6-29-8e1 THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESSA CURRENT FORMA' HASBEENFRED