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STATE OF CALIFORNIP WATER RESOURCES CONTR OARD <br /> FORIM 'S" UNDERGROUND STORAGE <br /> NANFORMATION ` <br /> TANK NK P 013 <br /> TANK PERMIT APPLICATION 7" <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 P MANENTLY CLOSED TANK <br /> MARK ONLY 6 TEMPORARY TANK CLOSURE TANK REMOVED O <br /> ONE ITEM �2 INTERIM PERMIT 4 AMENDED PERMIT , <br /> FARM TANK-YES❑ NO CJI <br /> �I. Q r <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: � <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> B. MANUFACTURED BY. <br /> A. YEARIOWNERS TALL IDN �� <br /> �/ D. TANK CAPACITY IN GALLONS: <br /> C. YEAR INSTALLED LY R <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> B C. 1 UNLEADED E] 2 LEADED 3 DIESEL <br /> A. MOTOR VEHICLE FUEL 2 PETROLEUM 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 3 CHEMICAL PRODUCT F-1 4 OIL <br /> E] 80 EMPTY u 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 5 HAZARDOUS <br /> DIF NOT MOTOR VEHICLE FUEL,ENTER NAME OF� ,1 C.A.S,W <br /> . <br /> HAZARDOUS SUBSTANCE STORED&CS q /4 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF rF-15 <br /> UBLE WALLED �3SINGLE WALLED WITH EXTERIOR LINER <br /> 95 UNKNOWN <br /> 99 OTHER <br /> SYSTEM GLEWALLED E]4 SECONDARY CONTAINMENT <br /> EEUAON 2 STAINLESS STEEL � 3 FIBERGLASS 4 STEELCLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK NCRETE Q 6 POLYVINYLCHLORIDE 7 ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> Fj 1 RUBBERUNED �2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR 95 UNKNOWN <br /> LINING ❑ 5 GLASS LINING 6 UNLINED <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' YES [] NO 99 OTHER <br /> D.CORROSION ❑ I POLYEFHLENEWRAP ❑�. 2 TARORASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION �5 CATHODIC PROTECTION L1a , NONE E]95 UNKNOWN E]99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U <br /> D <br /> 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 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 <br /> A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> A U 1 STEEL/IRON E A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRET <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 3 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 4 7 PRESSURE TESTING <br /> P S 91 NONE P S 95 UNKNOWN <br /> OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY G I INERT MATERIAL? YES E]NO <br /> 14 <br /> SUBSTANCE REMAINING IN GALLONS <br /> Niq <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWnLE DGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> FcU7 <br /> JURISDICTION <br /> AGE <br /> FACILITY IDM TANK ID N <br /> D6 1 Dl 3 oDDI <br /> pP©DYED BY N Fj PHONE N WITH AREA CODE <br /> ITY IDN , /�-- <br /> OPERMIT APPROVAL DA PERMIT EXPIRATION DATE <br /> ��J <br /> UMBER <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> FORMB(6-29-88) THIS FORM MUST BE ACCOMPA BY A FACILITY/OSITE APPLICATION, NGORCOPA',UNLESS JRRENT FORMA' HAS BEEN FILED <br />