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STATE OF CALIFORN� WATER RESOURCES CONTR OARD FORMV:: UND GROUND STORAGE TANK PRO RAM TANK TANK PERMIT APPLICATION INFORMATION m CO PLETE A SEPARATE FORM WITH THE FOLLOWTI NFORMATION FOR EACH TANK. t MARK ONLY , NEW PERMIT ❑3RENEWAL PERMIT CHANGE OF INFORMATION ❑7PERMANENTLY CLOSED TANK O ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ry 3 • g- FARM TANK-YES❑ NO (v 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPEC 4 - -.1 A. OWNERS TANK ID# B. MANUFACTURED BY: U co C.YEAR INSTALLED Q D. TANK,CAPACITY IN GALLONS. Q 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 PETROLEUMR. C. ❑ 1 UNLEADED E] 2 LEADED DIESEL F-13 CHEMICAL PRODUCT ❑ 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&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑i DOUBLE WALLED ❑35INGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM �NGIE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER TEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM [:j8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR r-11 ALILINED ❑2 ALKYD LINING ❑3 EPDXYLINING ❑4 PHENOUCLINING � ,�,, LINING ❑5 GIASSUNING ❑6 UNLINED 91 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VI WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A SINGLE 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLWSSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 Ur/S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 4i 6 PRECISION TESTING`P 8 7 PRESSURETESTING P 8 91 NONE P 8 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 IN GALLONS INERT MATERIAL? ❑YES [-] NO 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# = 0 11 F� 9s aoo CURRENT L AVOENCY FACILITY IDK APPRV -DIBYN �� PHONE#WITH AREA CODE PERMIT NUMBER S PERMIT APPROVAL DATE IO`3PERMIT EXPIRATION DATE CNECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# BY: iM FORM B(6-29-8B) THIS FORM MUST BE ACCOMPANIED Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS ATERENT FORMA' HAS BEEN FILED DATA PROCESSING COPY