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STATE OF CALIFORNI0 WATER RESOURCES CONTRO,OARD FORM W: UNDERGROUND STORAGE TANK PROGRAM 6 T'JANI�/ TANK PERMIT APPLICATION INFORMATION 1 " 1�1��IPL f9 A*9PAhATE FORM WIT14 THE FOLLOWING INFORMATION FOR EA61 tAkk. ' MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENT CL S ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMO ED yy FACILITY/SITE NAME WHERE TANK IS INSTALLED: ARM TANK-YES NO I. TANK DESCRIPTION co P ALL ITEMS-IF UNKNOWN-30 SPECIFY A. OWNERS TANK ID R u K., B. MANUFACTURED BY: C. YEAR INSTALLED - D. TANK CAPACITY IN GALLONS" (JT II. TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COM ETE ITEM D. CJI A. Mll MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNL D 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 A C.A.S.# C.A.S.4: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D / ATYPE OF ❑ WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER V/%UNKNOWN SYSTEM 102 SINGLE WALLED - ❑4 SECONDARY CONTAINMENT 99 OTHER ❑ I STEEL/IRON ❑2 STAINLESSSTEEL 3 FIB SS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYMNYL CHLORIDE ❑ LUMINUM 8 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRON2E ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER I RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING C. INTERIOR LINING ❑ ❑8 UNLINED 95 UNKNOWN 5 GLASS LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 1 OD%METHANOL? YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYMUNE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑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 I 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FISEROLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10096 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 8 1 VISUAL CHECK 0 8 2 INVENTORY RECONCILIATION 11 8 3 VADOSE WELLS 0 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING 0 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 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. APPLIQAM'$NAME(PRINTEDB SIGNATURE) DATE 6 4 LOCAL AGENCY USE ONLY ETI8 JURISDICTION# AGENCY# FACILITY 10 U TANK ID# CURRENT LOCAL AGENCY FACILITY ID 6 APPROVED BY NAME PHONE F WITH AREA CODE /V \� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE '& CHECK• PERMIT AMOUNT SURCHARGE AMT. - FEE CODERECEIPT# BY: N FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITEAPPLICATION, FORM 'AI,UNLESS CURRENT FORMA' HASBEENFILED