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STATE OF CALIFOR WATER RESOURCES CONT BOARD ,�`";� '� S; FORM `BU '. ND -RGROUND STORAGE TANK PR GRAM a s ma TANK PERMIT APPLICATION INFORMATION TAN Y - COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .c MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED PV FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ION rOTANK ANUFACTURED BY: AW F� ( l :�/ S C. YEAR INSTALLED CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,F-2!PLETE ITEM D. A, 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL vi PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 60 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.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DOUBLEWALLED ❑ 3 SINGLE WALLED WITHEXTERIORLINER ❑95 UNKNOWN SYSTEM rZ; SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-1I RUBBER LINED` ❑2 ALKYD LINING El EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR LINING F-] 5 GLASS LINING ❑6 UNLINED 5;i�UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT F7 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE VUNKNOWN ❑ 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 U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION Al LE 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 C. !MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD WfFRP A U 8 1G0%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A(ObS UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. y L P1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATE MONITORING WELLS `uilT'i f PS 6 PRECISION TESTING P S 7 PRESSURE TESTING 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 W INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED 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# /� /� TANK1101041 IDD# EffI - El I -I I Ll Loio-l / 1,-3111( V O il CURRENT LOCAL AGENCY FACILITY ID# APPROV D BY AME PHONE#WITH AREA CODE 1213 PERMIT U BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE A EIPT k 9Y: FORM B(6-29-a8) THIS FORM MUST BE ACCOMPANIED 9Y A FACILITYISITE APPLICATION, FO R M 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY