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STATE OF CALIFOR WATER RESOURCES CON L BOARD FORM ,8,. UN RGROUND STORAGE TANK P GRAM TAN � TANK PERMIT APPLICATION INFORMATION ✓ COMPLETE A SEPARATE FORM WITH THE FOLLOWING jXfORMATION FOR EACH TANK. MARK ONL;NAME ;INTE;RIMPERMIT T ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE ITEM ❑ ❑ 7 PERMANENTLY CLO 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE INSTALLED: Z2 L L — FA,RRM TANK-YES O ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY y_�p A. OWNERS TANK ID# B. MANUFACTURED BY: � C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: !r j If. TANK CO ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1), OT MARKED,COMPLETE ITEM D. A_ MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED ❑ 2 LEADED❑ DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 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.H 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,3 D A. TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER r 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ gg OTHER B.TANK 0 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBER G 1:14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 A INUM ❑B 100%METHANOL COMPATIBLE FAP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑l. EN 1C LINING LINING ❑5 GLASSLINING ❑ 6 UNLINED 95 KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? R ES 99 OTHER 0. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT VI WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 5 UNKNOWN ❑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 U 5 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 U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 GLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 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 P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH INERT MATERIAL? ❑YES ❑ NO ��GAL�LONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# AGILITY ID# TANK ID# E= _. CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME - PHONE X WITH AREA CODE PERMIT NUMBER --_� __-------- PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNTSURCHARGE AMT. FEE CODE � ECEJ� BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPAN.c BY A FACILITY/SIE APPLI TCATION, FORM `A',UNLESS A CURRENT FORMA' HAS BE ✓� ---- DATA PROCESSING COPY EN FILEDD