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STATE OF CALIFORNI WATER RESOURCES CONTRO ARD ` '• NDERf� ND STORAGE TANK PROM` ` FORM '13':. U OU ma TAN TANK PERMIT APPLICATION-INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -� z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION NE�1,7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / N FACILITY/SITE NAME WHERE TANK IS INSTALLED: i "'l f,). W i(S o A wARM TANK-YES NO O 1. TANK DESCRIPTION COMPLETE ALL LITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# C. r_0011616 i B. MANUFACTURED BY: Url C.YEAR INSTALLED u►� n�„/ D. TANK CAPACITY IN GALLONS: I GI If 11. 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 LEADED E]3 DIESEL ❑3 CHEMICAL PRODUCT F-14 OIL �'PfiODUCT ❑ 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&C.A.S.# C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 44 ; A.TYPE OF ❑ i DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT El 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASSREINFORgEDPLASTIG - - B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER F-] 1 RUBBER LINED ❑ 2 ALKYD LINING F-13 EPDXY LINING F-14 PHENOLIC LINING C.INTERIOR LINING F-]5 GLASS LINING ❑6 UNLINED :R�95 UNKNOWN ❑ ISLININGMATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑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 1,A U 95 U OWN 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 NO A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 IPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STE A NKNOWN 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELL 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED TsTE LAST UGALLONS ED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLEDFWITH 1. ' //„ SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES �NO (F THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO TH ST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(P NTED&SI TURE) I All - DATE K%m- I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# Eil 7_1 ---l— I 5 3 D 10-101 /1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE Uff PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: O FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS k aRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY _