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STATE OF CALIFORRU A WATER RESOURCES CONTOL BOARD FORM `BI: I ERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED:`� FARM TANK-YES❑ NO 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I A. OWNERS TANK ID# B. MANUFACTURED BY: 1 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q�Q 11. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COM?jm ITEM D. co A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. UNLEADEO ❑ 2 LEADED ❑3 DIESEL ❑ B.3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑SO 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&C.A.S.# C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 D09W WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SNGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 RBEWAASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALU ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C. LINING R ❑5 GLASS LINING ❑6 UNLINED NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 PGLYEfHLENE WRAP ❑2TAR OR ASPHALT ❑3 VINY P ❑ 4 RBERGIASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOV GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U RESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A�CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 8.,LEAK S 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/Y GALLONS 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E]YES [-] NO THIS FORM HAS BEEN&OMPLETED 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# [ I C)10 oma / CURRENT LOCAL AGE YFACILITY IDX APPROVED BY NAME HONE#WITH AREA CODE a 6 PERMIT NUMBER PERMIT APPROVAL DATE JFERMIrEXPIRATION CHECKX PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT X BY: FORM B(3-7-88) THIS FORM MUST BE ACCOMPANIE.v A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA HAS BEEN FILED DATA PROCESSING COPY