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�y CA p(( STATE OF LSFOf M6 . WATER RESOURCES CONTRI OARD ••�;w:,��. FORMV: UNDERGROUND STORAGE TANK PROGRAM) r L o TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 1 NEW PERMIT 3 RENEWAL PERMIT { MARK ONLY ❑ ❑X 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITE[ ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NALIE WHERE TANK IS INSTALLED: BP OIL COMPANY FACILITY SITE #11192 FARM TANK-YES❑ NO ® �' "J 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOVYN—SO SPECIFY —4 A. OWNERS TANK ID# UNKNOWN B. MANUFACTURED BY: UNKNOWN W C.YEAR INSTALLED 1974 D. TANK CAPACITY IN GALLONS: 3,000 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑- 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT L.X.1 4 OIL 01 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS I ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL O 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# MOTOR OIL C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTELI ®2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ® 1 STEEL/IRON ❑2 STAINLESS STEEL [:]3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC LIATERIAL B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE F-17 ALUMINUM E]8 10096 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ®6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER d4 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 H A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE 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. Lpp 8 1 VISUAL CHECK Q)8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 6 4 ELECTRONIC MONITOR P 8 5 GROUND WAT R MONITORING WELLS S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P S 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 GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NA (PRINTED&SI ATU DATE _T W.J. Hollis May 31, 1989 LOCAL AGENCY USE ONL COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# L'..I (� I UK] I I CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 11 WITH AREA CODE h 061(— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE "ECEIPT 0 BY: FORM B(6-29-88) THIS FORT!!JUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM`A',UNLESS NT FORLI'A' HAS BEEN FILED 1 DATA PROCESSING COPY