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STATE OF CALIFOR ► WATER RESOURCE ,CON BOARD FORMV: UNDERGROUND STORAGE TANK PROGRAM ; FO TANK �" TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOW WG FORMATION FOR EACH TANK. IO (MARK ONLY ® I NEW PERMIT 3 RENEWAL PERMIT [g'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK r ONE;ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHEREsTANK IS INSTALLED: FARM TANK-YES❑ NO (jJ CJ'1 1, TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY W A. OWNERS TANK 10 N B. MANUFACTURED BY: cy) C.YEAR INSTALLED uk_ D. TANK CAPACITY IN GALLONS: 1c,? c2 0 11. 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 Bh-l--PRODUCT C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ` ®3 CHEMICAL PRODUCT 4 OIL ❑ 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&G.A.S.N C-A.S.9: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑r2NGB� WAU ED ©3SINGLE wALLEo WITH EXTERIOR LlER ❑ 95 UNKNOWN SYSTEM WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELIMON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATiBLE FRP � MATERIAL. ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-11 RUBBER LINED ❑2 ALKYD UNING F-13 EPO)N LINING ZNOUC LINING LINING ❑5 GLASS LUNG ❑6 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑ ViAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 FiRERGLASSREINFORCED PLASTIC •+. PROTECTION ❑5 CATHODIC PROTECTION 51 NONE a 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFA VE 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 AU 95 NKNOWN A U 99 OTHER A U 1" EEL/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 M A U 6 CONCRETE A U 7 STEEL CLAD W/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 13E CIRCLED. PS I VISUAL CHECK P%6 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 T PRESSURE TESTING 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(MO/YH) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E-]YES ❑ NO THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, !S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYII JURISDICTION F AGENCY N FACILITY ID N TANK ID N F-1 r I / I & I o I ol I ol 7_771 CURRENT LOCAL AGENCY FACILITY NJ 11 APPROVED BY NAME PHONE II WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �f CHECK f ]PERMITAMOUNT RCHARGE AMT. FEE CODE IPT s BY: //Jj f � ' B(6-29-ea) THIS FORM BUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA` HAS BEEN FILED nAT: Q^Ow