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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM '9':� UNDEM;ROUNb STORAGE TANK PRO%FAAM LANK TANK PERMIT APPLICATION INFORMATION �1l MOL0 A bfpAhATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TAM. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑7 PERMANENTLYC NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED; '1-7 r FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID I I- ' B. MANUFACTURED BY: C. YEAR INSTALLED -( 0. TANK CAPACITY IN GALLONS: g"�D a 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ul A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 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 6 C.A.S.X C.A.S.X: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A"OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH WERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F1 SIEEI./IRON 2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCEDRASTIC B.TANK MATERIAL f❑5 CONCRETE ❑6 POLYVINYL CHLONDE ❑ 7 ALUMINUM ❑8 IM%METHANOL COMPATIBLE FRP ❑9 BPONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑8 UNLINED 95 UNKNOWN [-] 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C.INTERIOR 5 GLASS LININGI LINING ❑ ❑ ❑ B LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑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 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 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 FIRERGLASSPIPE 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 I VISUAL CHECK P 6 2 INVENTORY RECONCILIATION 11 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P • 6 PRECISION TESTING P E 7 PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P B 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 ElNO 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 P JURISDICTION R AGENCY P FACILITY ID 8 TANK ID R CURRENT LOCAL AGENCY FACT ID 0 / APPROVED BY NAME PHONE•WITH AREA CODE PERMIT NUMBER (/./(/^ v'/IJIL�L_ PERMIT APPROVAL DATE PERMIT EXPIRATION DATE. CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT P FORM B(6-29-aa) THIS FORM MUST BE ACCOMPANIftwA FACILITYISRT3 APPLICATION, FORM'A',UNLESS Av.AENT FORMA' HAS BEEN FILED DATA PROCESSING COPY