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A t Df CALIFOI;1IA WATER RESOURCES CO <br />FORM'S': U ERGROUND STORAGE TANK PROGRAM <br />*PLBOARD <br />TANKTANK PERMIT APPLICATION INFORMATION <br />GO LETS A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. <br />MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ,-j-, <br />ONE ITEM 2INTERIM PERMIT tL 5 CHANGE OF INFORMATION <br />0 4 AMENDED PERMIT ❑ 7 NMANENI <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED: / P7 — ( ❑ 6 TEMPORARY TANK CLOSURE <br />B TANK flEMOI <br />I. TANK DESCRIPTION Z COMPLETE ALL ITEMS-IFUNKNOWN— <br />� ��s �' " .5-/ S7� �/J �,crtPARM TANK -YES <br />A. OWNERS TANK IDA SO SPECIFY <br />C. YEA RINSTALLED B. MANUFACTUREDBY: <br />7 <br />TANK NTENTS D. TANK CAPACITY IN GALLONS: �•—i) <br />II. <br />Go <br />NO <br />IF (A•1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. J <br />A. I MOTOR VEHICLE FUEL E] 2 PETROLEUM ' <br />3 CHEMICAL PRODUCT C] 4 OIL 1TE-���I/I C. ❑ I UNLEADED 2 LEADED 3 DIESEL <br />5 HAZARDOUS <br />D. IF NOT MOTOR VEHICLE FUELu I PRODUCT 4 GASAHOL 5 JET FUEL <br />O EMPTY [1 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER (DESCRIBE❑IN TEMID BE <br />El BLOW) <br />, ENTER NAME OF <br />HAZARDOUS SUBSTANCE STORED d C.A.S. N <br />III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C'& D C.A.S. N. <br />A TYPE OF ❑ I DOUBLE WALLED 1:1 3 SINGLE WALLED WITH EXTERIOR LINER <br />SYSTEM 2 SINGLE WALLED r 4 SECONOAM CONTAINMENT ❑ 95 UNKNOWN <br />99 OTHER <br />B. TANK ElI STEEUIRON 0 2 STAINLESS STEEL ❑ 3 FIB <br />MATERIAL ❑ 5 CONCRETE 0 ERGLASS 4 STEEL Opp MAI REINFORCED PLASTIC <br />9 BRONZE <br />6 POLYVINYL CHLORIDE El 7 ALUMINUM B 100%ME7HANOLCOMPATIBLEFRP <br />1:1 10 GALVANIZED STEEL ED <br />95 UNKNOWN � 99 OTHER <br />C. INTERIOR I RUB_BERUNED ❑ 2 ALKYD LINING <br />LINING ❑ 5 GLASS LINING6 UNLINED ❑ 3 EPDXY LINING L_j 4 PHENOLIC LINING <br />© <br />IS LINING MATERIAL COMPATIBLE WITH IOD% METHANOL?El95 UNKNOWN <br />D. CORROSION ❑ I POLYETHLENEWRAP 2 TAO ORASPHALT YES ED NO 99 OTHER <br />PROTECTION5 GRIpDIC PROTECTION 9H NONE <br />❑ 3 VIWLWRAP 4 FISEAGLASSREINFORCEDPLASTIC <br />� <br />95 UNKNOWN 99 OTHER <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />A SYSTEM TYPE A U I SUCTION <br />B. CONSTRUCTION A U I SINGLE WALLED A U 1 PRESSURE A U 3 GRAVITY <br />A U 2 UOUBLE WALLED AU 91 NONE A U 95 UNKNOWN <br />A U 3 LIA U 99 OTHER <br />LIN TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br />A U 1 STEEL/IRON <br />C. MATERIALA U 2 STAINLESS STEEL <br />A U 5 ALUMINUM A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE <br />A U 9 GALVANIZED STEEL A A U U 6 CONCRETE A U 7 STEEL CLAD W/FRO A TI 91 NONE <br />U 95 UNKNOWN 99 OTHER A U B 108%METHANOL COMPATIBLE FRP <br />V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br />P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS <br />P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING <br />P S 91 NONE P S 95 UNKNOWN <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P B 99 OTHER -- <br />I. ESTIMATED DATELASTUSED Hun/Von <br />SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH <br />YES <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST •OF MY KNOWLEDGE, IS TRUEAND CORRECT NO <br />APPLICANT'S NAME (PRINTED 6 SIGNATURE) <br />DATE <br />COUNTY# <br />PERMIT NUMBER <br />I <br />JURISDICTION I <br />A7IGEENCY # FACILITY ID # <br />TANK ID Y <br />f % 7 <br />T FACILITY ID # <br />T -7 G � " <br />-7 APPROVED BY NAME <br />/ / PHONE I WITH AREA CODE <br />PERMIT APPROVAL DATE PERMITEXPIRATIONOATE <br />PERWTAMOUNT SURCHARGE ANT. <br />FEE COOS <br /># <br />w FOHMBl6-29-BB) THISFORMMUSTBEACCOMPANIED AFACILITY/SITEAppLICATION, 11 FORM' BY: <br />DATA PROCESSING COPA,�UNLESSACURRENT FORMA' BY: <br />