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. _. •--^'_ ___-r ;;�r,� •_.c. .k�'^rr.�..:€�+r� ,STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD PotR FOAM IB': UNDERGROUND STORAGE TANK PROGRAM Rw ��i510 TANK 00, . . TANK PERMIT APPLICATION INFORMATION C�MPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK!. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF.INFORMATIONPERMANENTLY CLO ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑fi TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: b L ARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 5 •� A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED J D. TANK CAPACITY IN GALLONS: 11. TAN ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM/D. A. TEMD- A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C E] 1 UNLEADED ❑2 LEADED IESEL ❑ 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 l! HAZARDOUS SUBSTANCE STORED&C.A.S.9 II. C.A.S.0: R f III. TANK CONSTRUCTION MARK ONEATEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑ 99 OTHER ❑ 1 STEELII%N ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑bell UMINUM ❑ 8 10Q%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALYANIZEDSTEEL NKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING �ENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 95 KNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10046 METHANOL? ❑YES ❑ NOHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT E��VULWRAP ❑4 FIBERGLASSREINFORCEDPLASTIC PROTECTION. ❑ 5 CATHODIC PROTECTION El91 NONE KNOWN E:]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 5 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A;'U 2 DOUBLE WALLED A U 3 LOPED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A i-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 6 CONCRETE A U 7 STEEL CLAD W/FAP A U a 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL ,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 S 2 INVENTDRY RECONCILIATION P S 3 VADDSE WELLS P 4 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS _ P S fi PRECISION TESTING P S 7 PRESSURE TESTING, P S 91 NONE P $ 95 UNKNOWN P $ 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 h THIS FORM HAS-BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIG NATURE) . ' - DATE +. >i LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D D /I LO10MO3 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE 0 WITH AREA CODE PoAtip- fj PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE z _Z e CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-aa) THIS FORM MUST BE ACCOMPANI BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A URRENT FORM'A HAS BEEN FILED DATA PROCESSING COPY