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7V y-3 687 STAT A 1 NI WATER RESOURCES CONTRARD FO GROUND STORAGE TANK PROGRAM TAIV NMENTAL HE K PERMIT APPLICATION INFORMATION RMITIj , F SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. s^"'" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE5WNENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TklANK REMOVED D FACILITY/SITE NAME WHERE TANK IS INSTALLED: s*.} 6G =ooD ,ke T -2 X D lU- E F M TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# 7 N--3(qt&7- ,eL) -1 B. MANUFACTURED BY: C.YEAR INSTALLED 19616 D. TANK CAPACITY IN GALLONS: �O OOO 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 F-� 2 PETROLEUM B. C. © 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Fx-1 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN 2 WASTE El 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ®2 SINGLE WALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS F-14 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑5 CONCRETE 6 POLYVINYLCHLORIDE F-� 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP Ej 9 BRONZE 1:1 10 GALVANIZED STEEL [::]95 UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKYD LINING F-1 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR LINING ❑5 GLASS LINING ©6 UNLINED ❑ 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [-] NO 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP F-] 2 TAR OR ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Ej 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A®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(Sq 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. P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 PEN TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S N (P INTE &SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# El I I I I I / 6 LLI0D -Tv-1 CURRENT LOCAL AGENCY FACILI # APPROVED BY N ME ' /` PHONE#WITH AREA CODE _3 -� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE L4RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM'A',UNLESRENT FORM`A' HAS BEEN FILED DATA PROCESSING COPY