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ARD <br /> pRN1� WATER RESOURCES CONTROL <br /> RGROUND STORAGE TANK PROGRAM <br /> STATE <br /> OF CALIF NDEINFORMATION <br /> u <br /> ORM `09' K PERMIT APPLICATION FORAT EACH TANK. TLY CLOSED TANK <br /> F TAN ❑7 pERMANEN <br /> TANK COMPLETE A SEPARATE FORM WITH THE FO ❑5 CHANGE OF INFORMATION ❑B TANK REMOVED <br /> ❑1 NEW PERMIT ❑3 RENEWAL PERMIT <br /> ❑6 TEMPORARY TANK CLOSUR NO ❑ <br /> MARK ONLY 2 INTERIM PERMIT <br /> ❑4 AMENDED PERMIT FARM TANK-YES <br /> ONE ITEM ❑ <br /> FACILITY/SITE NAME WHERE TANK IS INE AL NEMS-IF UNKNOWN—SO SPECIFY <br /> 1. <br /> COMPLETE B. MANUFACTURED BY'. <br /> TANK DESCRIPTION <br /> D. TANK CAPACITY <br /> A. OWNERS TANK ID# IN GALLONS'. �' <br /> 2 LEADED ❑3 DIESEL <br /> C.YEAR INSTALLED C ❑1 UNLEADED ❑ 6 AVIATION GAS <br /> COMPLETE ITE <br /> IF(p 1) IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED, ❑ <br /> B' ❑4 GASAHOL ❑5,JET FUEL <br /> II. TANK CONTENTS ❑2 PETROLEUM ❑1 PRODUCT 7 METHANOL ❑gg OTHER(DESCRIBE IN ITEM D.BELOW) <br /> A. ❑1 MOTOR VEHICLE FUEL ❑ <br /> ❑3 CHEMICAL PRODUCT ❑4 OIL5 UNKNOWN ❑2 WASTE <br /> ❑80 EMPTY C.A.S.#: <br /> ❑5 HAZARDOUS Lb <br /> NAME <br /> D. IF NOT MOT <br /> CLE FUEL, <br /> HAZARDOUSOSUBSTANCE STORED&ENTERC.A.S.#OF <br /> MARK ONE ITEM ONLY IN BOX A,B+C•&D 9UNKNOWN <br /> III, TANK CONSTRUCTION ❑3 SINGLEWALLEDWITHEXTERIORLINE' ❑ 5 5 99 OTHER <br /> A.TYPE OF ❑ 2 OUBLEwALLED SINGLE WALLED ❑4 SECONDARY CONTAINMENT <br /> ❑ 3FIBERGJ+SS ❑4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> SYSTEM <br /> ❑1 STEEUIRON ❑2 STAINLESSSTEEL 11 NUM 6 100%METHANOLCOMPATIBLEFRP <br /> 6 POLYVINYL CHLORIDE ❑ A NUM ❑gg OTHER <br /> B.TANK ❑5 CONCRETE ❑ g5 UNKNOWN <br /> 10 GALVANIZED STEEL <br /> MATERIAL ❑ BRONZE ❑ 3 EPDXY UNING ❑4 PHENJCL',"- <br /> 9 <br /> ❑1 RUBBER LINED <br /> ❑2 ALKYD LINING ❑ UNKNOWN <br /> 5 GLASS ❑6 UNLINED ❑ NC gg OTHER <br /> LINING <br /> C.INTERIOR ❑ YES ❑ ❑ <br /> LINING ❑ISLININGMATERIALCOMPATIBLEWITH100%METHANOL? —o�STIC <br /> 3 VI 4 FIBERGLASS <br /> ❑ IL='•=- <br /> ❑2 TAR OR ASPHA_T ❑ ❑gg OTHER <br /> PROTECTION ❑5 CATHODIC PROTECTION <br /> 1 POLYEHLENEWRAP g5 UNKNOWN <br /> D.CORROSION E] ❑g1 NONE <br /> NG INFORMATION A U 3 GRA,,n A u <br /> CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND BOTH IF APPLICABLE <br /> IV. <br /> PIPING A U 2 PRESSUR_ _•,_ U _�5 U KNOWN A U K <br /> A.SYSTEM TYPE A U 1 SUCTION A U 3 LINED TRB.Ck p U - <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED <br /> A U 2 STAINLESS STEEL A U 3 POLYVINYL CN.ORIDE(PVO A U 4 FIBERGLASS PIPE A U = <br /> 1 STEEL/IRON A U 7 STEEL CLAD W:-,RP A U 8 100%VE'ANOL COMPAT E =P <br /> A U A U 6 CONCRETE <br /> C.MATERIAL A U S ALUMINUM 5 UNKN A U 99 OTHER <br /> A U 9 GALVANIZED STEEL <br /> P S 99 <br /> ST <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY. <br /> A PRS 95 UNKNG.ti MARY�LEAK�DETE DETECTION SYSTEM M R MOBEo CIRCLED. <br /> s <br /> 2 I-,�ENTORY RECONCILIATION P S 3 NODOSE WELLS P S <br /> P S P g gt NONE _ <br /> p S 1 VISUAL CHECK � PRESSURE TESTING <br /> P S 6 PRECISION TESTING P S <br /> 3 0.AS TANK FLLED WITH <br /> VI. INFORMATION ON TANK PERMANENTLY ESTIMATED2. QUANTITY <br /> IN OF %ERT MATERIAL? ❑YES <br /> 1.ESTIMATED DATE LAST USED(MO,YR SUBSTANCE REMAINING IN GALLONS — <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNC.YLEDGE, IS TRUE AND CORQE�:- <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY AGENCY# FACILITY ID w <br /> COU NTY# JURISDICTION# � O <br /> E= <br /> 37 pppR VED BY NAME PHONE><W rrH AREA CODE <br /> CURRENT LOCAL AZ2 ,.VCy FACILITY ID N <br /> LZ <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT NUMBER <br /> CHECK N PERMIT AMOUNT <br /> SURCHARGE AMT. FEE CODE RECEIPT t BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/DSITE APPLI ATION9 FORD A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br />