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STATE OF CALIFORN_1 WATER RESOURCES CONT( BOARD FORM 'S': UNDERGROUND STORAGE TANK PR*GRAM ` TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ __ z MARK ONLY ❑ 1 EW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE Of INFORMATION ❑ 7 PERMANENTLY CL//O$$��p� TANK O ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED&* FACILITY/SITE NAME WHERE TANK IS INSTALLED: W. w div ARM TANK-YES NO EPrj 4b- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ( ~ r A. OWNERS TANK 0# B. MANUFACTURED BY: C W C. YEAR INSTALLED 54 1 i oiD. TANK CAPACITY IN GALLONS: H. TANK PONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB� ` C. ❑ 1 UNLEADED E] 2 LEADED 3 DIESEL F-13 CHEMICAL PRODUCT ❑4 OIL I 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 8 C.A.S.# C A.S.q: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A TYPE OF BLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWAUED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ;❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%MEFHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-] 1 RUBBER LINED E] 2ALKYD LINING ❑3 EPORY LINING ❑ 4 ENOLIC LINING LINING F-15 GLASS LINING F-16 UNLINED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? I❑III YY��/EES ❑ NO �89 OTHER "blt k D.CORROSION ❑ 1 POLYEMLENEWRAP ❑ 2 TAR OR ASPHALT Q/VINYLWRAP F-] 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 AM 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH 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 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AU 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 1W%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. VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS fl 1 S fi PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER C/ `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? DYES [:] 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION R AGENCY R FACILITY ID R TANK ID B m9 00 1 1 7f I 1010 10 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE r,Al 641%117 G✓,es PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Z8 CHECKN PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTN BY: Lt FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANXV&A FACIUTY/SRE APPLICATION, FORM 'A',UNLESS VIRIIIIIENT FORMA' HAS BEEN FILED DATA PROCESSING COPY