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N STATE OF CALIFORA WATER RESOURCES CONTA BOARD FORM'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF TION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ED�ANK 1 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED D7 11 ONE ITEM ED 2 INTERIM PERMIT D ❑ ❑ �Z,� FARMTANK-YES❑ NO FACILITY/BITE NAME WHERE TANK IS INSTALLED: [ Jc' { I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN -80 SPECIFY FF A OWNERS TANK 10 B B. MANUFACTURED BY: 4111t- D. 1(/t-D. TANK CAPACITY IN GALLONS: It. TANK CONTENTS IF (A.1). 18 MARKED, COMPLETE ITEM C. IF (A.1). IS NOT MARKED, COMPLETE ITEM D. B C. UNLEADED ❑ 2 LEADED ❑ 0 DIESEL A MOTORVEHICLE FUEL ❑ 2 PETROLEUM al —PRODUCT ❑ / OASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 0 CHEMICAL PRODUCT ❑ 1 OIL ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM 0, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF CA.S. N: HAZARDOUS SUBSTANCE STORED 6 C.A.S. B III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A. S. C. A D PIEWAILID ❑] SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN ❑ / SECONDARY C1NT(AINMEM ❑ 99 OTHER 2 9STFEUIRON ❑ 2 STAINLESSSIEEL ❑ 7 FIBERGLASS ❑ 1 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC ❑ 5 CAVDETE ❑ 6 POLYWNR.CHLOPoDE ❑ 7 ALUMINUM ❑ 81W%METVUNOLCOMPATIBLEFRP ❑ 9 BfDNZE❑10GALVANIZEDSTEEL❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUTIBERUNED ❑ 2 NING ❑ 7 EPDXYUNING ❑ 1 PHENOLIC LINING ❑ S GLASSUNINO UNJNED ❑ 95 UNKNOWN ❑ IS LINING MATRIAL COMPATIBLE WITH IW%METMNOL7 ❑YES ❑NO 990TMEF ION ❑I POLYETTK➢IEWPAP2 TM OR ASPHALT ❑ ] W WRAP ❑ 1 FIBETIGLASSREINFORCEDPUSTIC TION ❑ 5 GRKIGIC PROTECTION ❑ 91 NONE UNI(NOWN ❑ 97 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A SYSTEM TYPE 1 SUCTIO A U 2 PRESSURE A U 9 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 G LINED TNENCH A U 91 NONE A U 5 N A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 7 POLWINYI CHLORIDE (PVC) A LA I FIBERGLASSSS PIPE A U 91 NONE C. MATERIA. A U 5 ALUMINUM A U 6 A U 7 STEEL CLAD W/FRP A U 9 1O METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A BS UNKNOV - A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P t 1VISUAL CNECK P B 2 INVENTORY RECONCILIATION P B 3VADOSE WELLS P B I ELECTRONIC MONITOR P 6 5 GROUND WAI ER MONITORINGWELLS P B 6 PRECISION TESTING P B 7 PRESSURE TESTING P B 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 9 Y,rAS TA NK FILLED WITH I. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF T ATERIAL'! DYES 0 N GALLONS SUBSTANCE REMAINING IN INEFlM- THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEE DATE APPIJGN7'S NAME (PRINTED 6 SIGNAL URE) ;AL AGENCY USE ONLY COUNTY B JURISDICTION B AGENCY I FACILITY TO E BRENT LOCAL AGENCY FACILITY ID E APPROVED BY NAME N 7 -/-- c;'l PERMIT NUMBER PERMIT APPROVAL DAT! PERMIT F PERMIT AMO WRCHARGE AMT. I FEECODE RECEIPT 1 IS TRUE AND CORRECT. TANK 10 B PHONE I WITH AREA CODE