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1 TEO 'CALIFORNR� WATER RESOURCES CONTRO�OARD {•''. UNDERGROUND STORAGE TANK PROGRAM X.. ;FORM 13.'.' ., a; TANK PERMIT APPLICATION INFORMATION NK= COMPLETE A SEPARATE FORM WITH THE FOLLOWINOJNF.ORMATION FOR EACH TANK. ^'' z MARK ONLY, ;.._' ,1 ❑1 Nk1N PERMIT .: ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL A ONE ITEM',�,i;; ❑,2 INTERIM PERMTf. ❑4 AMENDED PERMIT. ❑B TEMPORARY TANK CLOSURE ❑8 TANK REMOVED e✓ ^' FACILTTY/SITEryNAME WHERE TANK 18 INSTALLED: TANK-YES NO ❑ I V L'TANK DESCRIPTION' COMPLETE ALL ITEMS.IF UNKNOWN—80 SPECIFY A OWNERS TANK IDN ;. B, MANUFACTURED BY: YEAR INSTALLED, :; 0. TANK CAPACITY IN GALLONS: D ,.11, TAN K CLATENTS 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.'i❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRovucT ❑4 OIL 1 PRODUCT ;❑4 GASAHOL ❑6 JET FUEL ❑6 AVIATION GAS ❑5.HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE I❑ 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VENCLE FUEL,ENTER NAME OF I HAZARDOUS SUBSTANCE STORED&CAS.N. O C.A.S.M R' Y 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A D t DOUBLE WALLED 3 SINGLE WALLED WITH EXIEra FI LOO 95 UNKNOWN . . �TYPE OF ' �❑�. ❑ ❑ SYSTEM. ❑2 51NGIli;WAm ❑4 SEC410ARY CONTAINMENT ❑99 OTHER ❑t sTEEI JJBIa! ❑2 STAINLESS STEEL ❑a RBERGUM ❑`i STEEL CLAD W/FSEWAASS REINKKM PLASM L TANK ❑5 CONCRETE . . ❑B POLYVRTP OLORIDE ❑i ALUMINUM ❑e OL IW%MFAQlCOMPATIBLEFW MATERIAL'.. ❑9 BRONZE ❑10 GALVANIZED STEEL E].%UNKNOWN ❑99 OTM AiwrERloR . ❑ t,RJfI=UNED ❑2A MLIN�ING ❑3 EPDXY LINING ❑ PHENOLIC LINING LINING. .❑5 UMLIM14 ❑6 UNLINED ❑95 UNKNOWN :`'. ❑IS�JNONI MAT91ACOMPATB3I.E WM IM%METIIMIOL7 ❑YE5 C]NO ❑99 OTHER D,CORROSION .:. ❑.t POLYEIFLENE WRAP : ❑2 TAR ORASPHALT ❑9 WHY(WRAP ❑4 FIBERGLASS REINFORCEp PLASTIC PROTECTION ❑.3 GTNgDICPR07ECTlON ❑e1 NONE ❑95 w alm ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IFUNOERGROUND,BOTH IFAPPLICABLE 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 A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL;l A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.YATULAL A U 5 ALUMINUM A U 6 CONCRETE :s A U 7 STEEL CLAD iNIFRP A U B 100!6 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER j ' . V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 81 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P 11 3 VADOSE WELLS P 11 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECIDON TESTING P 6 7 PRESSURETESTINO P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER Vt. INFORMATION ON TANK PERMANENTLY CLOSED IN PUKE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF3.WAS TANK FILLED WITH 6UBSTANCE REMAINING iN GALLONS INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE EIEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUcANT's NAME(PRINTED s SIGNATURE) I DATE R 5 1 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N EMd / '7 / dQ6 CURRENT LOCAL AGENCY FACILITY NDNAPPROVED BY NAME PHONE/WITH AREA CODE PERMIT NUMBER - PERMIT APPROVAL DATE PERMIT:EXPIRATION DATE . i CHECK/ PEAMIT AMOUNT8URGHAROE AMT. FEE CODE RECEIPT# BY:`- < d !/✓ �' FORM B(&297HB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `X.UNLESS A CURRENT FORM W HAS BEEN FILED _