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STATE OF CALIFORN� WATER RESOURCES CONTR�BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM - TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY NEW PERMIT F-]3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL i ONE ITEM 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑0 TANK REMOVED i S "A FACILITY/SITE NAME WHERE TANK IS INSTALLED: D ks #C RLQ ARM TANK-YES❑ NO O 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 9,-376 P A. OWNERS TANK IDR B. MANUFACTURED BY: Ell i C. YEAR INS LLED I D. TANK CAPACITY IN GALLONS: 0-rw II. TANK ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),!S NOT MARKED,COMPLETE ITEM D. A. tj 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑4 OIL 1 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&C.A.S.R CAS.R: III. TANK CONSTRUCTI N MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM M 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESSSWEL 3'FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE E]8 POLYVINYLCHLORIDE 7 ALUMINUM ❑0100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHBI ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ ENOUC LINING Eo C. INTERIOR LINING F-15 GLASS UNING ❑6 UNUNED 95 ❑ ISUNING MATERIALCOMPATIBLEWITH 10D%METHANOL? ❑YES ❑ NO OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT INYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMAJAON 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 B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A:(!, STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A Al 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 JL LEAK DETECTION SMTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 3 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 El 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 B SIGNATURE) DATE LN oa d /1 140 -2 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FACILITY ID# TANK ID R CURRENT LOCAL A CY FACILITY ID# APPROV PHONE 0 WITH AREA CODE PFAYIT NUMBER PERMI PPROVAL DATE PERMIT EXPIRATION DATE /YJ - CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILTTY/BTTE APPLICATION, FORM `A',UNLESS n CURRENT FORMA' HAS BEEN FIILLEEDD DATA PROCESSING COPY