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STATE OF CALIFORNIft WATER RESOURCES CONTRARD FORM `13% UNDE GROUND STORAGE TANK PRO*:)AM TANK TANK PERMIT APPLICATION INFORMATION • .gym COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' MARK ONLY ❑ N RMIT ❑ 3 RENEWAL PERMIT ❑�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I ONE ITEM INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0 FACILITY/SITE NAME WHERE TANK IS INSTALLED: j FARM TANK-YES❑ NO may, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO ECIFY A. OWNERS TANK 1D# rQ B. MANUFACTURED BY: ��' O C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: U II. TANK CO ENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COM TE ITEM D. f` A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADEQ ❑ 2 LEADED E] 3 DIESEL F-] 3 CHEMICAL PRODUCT F] 4 OIL 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 A C.A.S.H C.A.S.H: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,d D A.TYPE OF ❑ I DIDUCE WALLED ❑3 SINGLE WALLED WITH EkTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGL WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER .TANK 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 IOD%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 AL `NAG ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1 M%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI RAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 5 UNISNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 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 3 LINED TRENCH A U 91 NONE A CU 5 UNKNOWN A U 99 OTHER A U 1 STEELARON 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 U6 CONCRETE A U 7 STEEL CLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP , A U 9 GALVANIZED STEEL 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 I VISUAL CHECK S 2 INVENTORY RECONCILIATIONP 5 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S� PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANyK� PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST SE 0/ 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH /'!l//� SUBSTANCE REMAINING IN 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 APPLICANT'S NAME(PRINTED 8 SIGNATURE} TATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# r7l �Tp _ 1 C13] CURRENT LOCA y FA Ip APPROVED BY NAME PHONE k WITH AREA CODE i� ,� PERMIT NUMBER PERMIT APPROVAL GATE PERMITtXPIRATIOW6ATE CHECK>R PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-6a) THIS FORM MUST BE ACCOMPANIE Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY