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STATE OF CALIFORNI WATER RESOURCES CONTROARD FORU'B': UNDERGROUND STORAGE TANK PROG AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 4. ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ( TANK REMOVED 111 0, FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 O FARM TANK-YES❑ NO i I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT 0 A. OWNERS TANK ID Lti K B. MANUFACTURED BY: l..v C. YEAR INSTALLED D. TANK CAPACITY INGALLONS'. S�� 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM BC. E] 1 UNLEADED [:] 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT E�4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS 1:180 EMPTY ❑ 95 UNKNOWN WASTE ❑ 7 METHANOL Fvr9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# S�6' o/ / C.A.S.N: 0 JR. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,&D A TYPE OF F-11 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ©1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 810096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIOR ❑ 5 GLASS LINING 1:16 UNLINED [�]15 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑ NO ❑ 99 OTHER 0.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE ro 95 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 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 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 i ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH A ,� SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES F] NO A THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 60 / l6 � o / CURRENT T LOCAL A(9EQNCY FACILITY IDN APPROVED BY NAM ENJ PHONE N WITH AREA CODE GKS as g�VF PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: 1/ / ORM B(3-7-BB) THIS FORM MUST BE ACCOMPANI BY A FACILITY/SITE APPLICATION, FORM kUNLESIWRRENT FORMA' HAS BEEN FILED J/ y' DATA PROCESSING COPY