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STATE OF CALIFORNIA WATER RESOURCES CONTROL BqfD FORM BE: UNDERGROUND STORAGE TANK PROGR TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT S CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' i. 7- FARM TANK•YES❑ NO L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-60 SPECIFY _ A. OWNERS TANK ID I B. MANUFACTURED BY: C.YEAR INSTALLED I q i. ; q Y O. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),K MARKED,COMPLETE ITEM Q IF(A1),15 NOT MARKED, MPLETE rTEM D. A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. i UNLEADED ❑Z LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑N OIL ❑1 PRODUCT ❑N GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑SO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.N CA.S.N: 111. TANK CONSTRUCTION MARK ONE TTEM ONLY IN BOX A,B,C•a D A TYPE OF ® 1 DDUDEWAUED ❑3 SINGLE WALIFD WITH EXTEROR VIER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWAUED ❑A SEC010AINCGNTARIIENT ❑99 OTHER ❑I STEELIRON ❑2 SIANLESS OR ❑3 FBEROIASS ❑H STEEL CUD WI BEIGLASS REWORCM PLASTIC L TANK ❑5 CONCRETE ❑6 POLYVINYL GLOME ❑ 7 ALUMINUM ❑S 1W%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 19 GALVANIZED STEEL ❑95 IINKNOAN ❑99 OTHER ❑ I RIN8ERU0) ❑2 ALKYD LINING ❑3 EPDXY URW ❑1 PHENOLIC LING C LINING F-15 GLASS LINING �6 UUNED ❑ LNN 95 NOWN IS LINING MATERIAL COMPATIBLE WITH IM%MELNAINIL' ❑YES E)NO ❑99 OTHER B.CORROSION ❑ I POLYEMENEWRAP ❑2 TAR ON ASPHALT ❑3 VWL WRAP ©N FEEPGLASSPEINF0IICED PULSTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NOTE ❑95 UMNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION —AE_ A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U "OTHER B.CONSTRUCTION A U I SINGLE WALLED A / 2 DOl7E WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U N OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A cm,A FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/ERP A U 8 1"METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U M 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 If 1 VISUAL CHECK PR/ 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS OF E A ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P 9 6 PRECISION TESTING P E ] PRESSURE TESTING P S 91 NONE P E 95 UNKNOWN P A 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I ESTIMATED DATE UST USED(MOIYR) 2 ESTIMATED OUANTITYOF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GA"OI/% INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN TO`T E jfftT OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE G.J. MEYER-U.G.T.ANALYST i3 90 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N CILITY ID N TANK ID N _=z- CU [NT LOCAL AG[NCY FACILITY ID I IIPPIAOVED 9Y IAN[ ►HONE E WITH AREA CODE EL. MJIYR NUYOER rtRYIT APMOVAL DATE MRNR QPMATHNI GATE CHECK F 7iRYR AYOUIR EUACHARD[AMT. ME CODE AECEIIT F FORMB(629-06) THIS FORM BUSY KACCOWANU E1 A FACLITY/SITE APPLKAT10K FORM'A',UMIEUACUWW FDBM'A' HASBEENFLED ? 1 DATA PRC -SING COPY 2 LOCAL AGENCY COPE' . -A COPY