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FORM '13% UNDERGRONDPSE MIAGE T APPLICATION I FORMAIRON and/or COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 NEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 TANK REMOVED ONE ITEM ❑2 INTERIM PERMIT d AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 PERMANENTLY CLOSED TANK FARMTANK-YES❑ NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK I.D.N B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM B.IF(A.1),IS NOT MARKED,COMPLETE ITEM C. A. ❑ i MOTOR VEHICLE FUEL F—] 2 THER PETROLEUM PRODUCT B. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT 4 WASTE OIL ❑ d GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 OTHER HAZARDOUS WASTE ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM C,BELOW) O IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.4 III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOX A,B,C,D 1 DW BLE WALLED ❑ 2 SINGLE WALLED ❑3 SINGLEWALLEDWITHEXTEF.ORLINER A TYPE OF — SYSTEM ❑ 4 SECONDARY CONTAINMENT ❑95 UNKNOWN 99 OTHER ❑ I STEEUIRON ❑ 2 STAINLESSSTEEL ❑3 FIBERGLASS d STEEL CLAD WIFIEERGLASSPE:NFORCEDPLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑810D%METHANOLCCMPATIBLFRP MATERIALOTHER ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 PHENOLIC ❑ I RUBBER LINED �LKYO LINING F-13 EPDXY UNING ❑ d PHENOLIC LINING C. INTERIOR ❑ 5 GLASSUNING 6 UNUNED ❑91 NONE ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 10016 METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAAORASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROCTECTION ❑ 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 1 SUCTION A U 2 PRESSURE A GRAVITY A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) 4 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 4 VADOSE WELLS PO4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS S 6 PRECISION TESTIN 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(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INERT MATERIAL? E]YES ❑ NO In GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLIC T'S NAME(PRINTED 851GNATI RE) i.'o"i2go/( Z'Q DATE D � LOCAL AGENCY ILIA ONLY L COUNTY N JURISDICTION N AGrENCY M FACILITY ID 9 TANK ID X CURRENT LOCAL AGENCY IO N rC.ECK NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE FEE CODE N AMOUNT SURCHARGE AMT. RECEIPT♦ BY: FORM B(1-Ba) THIS FORM MUST BE ACCOMPANIED BY A FACILRY/SITE APPLICATION,FORM W,UNLESS A CURRENT FORM 'A' HAS BEEN FILED