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STATE OF CALIFORN1 0 UND WATER RESOURCES CONTRO ARD FORM FB': ERGROUND STORAGE TANK PRODRAM � TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FACH TANK. � t r ,`9�,Frau•' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT } ONE ITEM ❑ ❑q AMENDED PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO SED T K 2 INTERIM PERMIT ❑ 6 TEMPORARY TANK CLOSURE (-7 FACILITY/SITE NAME WHERE TANK IS INSTALLED. ❑B TANK REMOVED FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— O SPECIFY A. OWNERS TANK ID# zs / N B. MANUFACTURED BY; C. YEAR(INSTALLED D. TANK CAPACITY IN GALLONS: 6 0 try d !!. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. FD� IF 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C- ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT �OIL �-1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ��'❑2 WASTE7 METHANOL IBJ ygOTHER(DESCRIBE IN ITEM D,BELOW) OT MOTOR VEHICLE FUEL,ENTER NAME OFARDOUS SUBSTANCE STORED&C.A.S.# O / III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,S D CAS #, A.TYPE OF OUBLE WALLED E] 3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM 2 SINGLE WALLED ❑95 UNKNOWN 4 SECONDARYCDNTAINMENT ❑99 OTHER B.TANK STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑9 BRONZE ❑B 10096 METHANOL COMPATIBLE FAP 1110 GALVANIZED STE€L E]95 UNKNOWN II�� ❑99 OTHER C. INTERIOR l�J 1 RUBBER LINED ❑2, D LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑S GLASS LININGgf-T16"UNLINED IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? E]YES NO F-1 95 OTHER WN E] D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT PROTECTION ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC ❑5 CATHODIC PROTECTION E]91 91 NONE ❑ UNKNOWN ❑99 OTHER !V. PIPING INFORMATON c RCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A u 2 PRESSURE B. CONSTRUCTION A 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 A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE U C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 9 GALVANIZED STEEL A U 5 UNKNOWN A U 7 STEEL CLAD W/ERP A U 99 OTHER A U 8 100%METHANOL COMPATIBLE FRP V.LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED, Q P S 1 VISUALCHECK S 2 INVENTORY RECONCILIATION p [JnS 3 VADOSE WELLS P S d ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS � P S 6 PRECISION TESTING P S 7 PRESSURE TESTING. P S 91 NONE P S 95 UNKNOWN V!. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s 99 ©TREK 1. ESTPMAZ=7_ 2. ESTIMATE QUANTITY OF —::: SUBS E EMAINING IN 3. VVAS ANK FILLED WITH GALLONS ATERIAL? ❑YES ❑ NO THIS FORM' BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6.SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENTT GENCY FACILITY Ip# APPR VENAME PHONE!1 WITH AREA CODE PERMIT N �Ir p PERMIT APPROVAL DATE PERM T E PIRATION DATE CHECK fi PERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEIPT11 BY: FORM(6-29-88) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY /