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1 <br /> STATE OF CALIFORNIA WATPA AESOMCES CONTROLn` <br /> FrjgM 'g': UNtIFA �OUND StOgAOE TANK pgOGHA �' � <br /> `TANK �, . `fiA PA AttrMIY <br /> APPLIOATION INPOgMATION. � <br /> ��r}�fW1pL@#i M b@pA Air:pOgM WITH tHt FIyLLOWINa INFORMATION Rtlq FAIN tAgk,',.I,,. <br /> MARK ONLY LJ I NEW PERMIT rl 3 RENEWAL kAMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C <br /> ONE ITEM I INTERIM pERMIt rl 1 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE Ej8 TANK REMOVED /� <br /> FACILITY7SItt NAME NHERE,TANK IS INSTALLEbL G 1 ARM LANK-YES❑ No I. C <br /> I. TANKDESCAIPTION COMPLEftALL ITEiAS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID N B. MANUFACTURED BY: <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /Z d6O Q <br /> 11. TANK CONTENTS IF(A. IS MARKED,COMPLETE ITEM C.IF(A. ).IS NOT MARKED,COMPLETE ITEM D. <br /> � . <br /> A. ❑1 MOTOR VEHICLE FUEL 2 PETROLEUM n. C. ❑ I UNLEADED Lj 2 LEADED DIESEL 01 <br /> 3 CHEMICAL PRODUCT F1/ OIL 1 PRODUCT <br /> GASAHOL 0 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS E]AO EMPTY 95 UNKNOWN 2 WASTE [:] .7 METHANOL [—]99 OTHER(DESCRIBE IN ITEM R BELOW) /_5 <br /> O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C AS,8: 77�� <br /> HAZARDOUS SUBSTANCE STORED A C.A.S.N 111 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.R,C,A 1) 3 TLI� <br /> A.TYPE OF I DO&EWALLED F]I SINGLE WALLED WI NEXTEROR UNER ❑95 UNKNOWN <br /> SYSTEM 2�5NGLp WALLED 1 SEMMOARICONTANMENT 99 OTHER <br /> I SIEELIIRON 2 SIAINLESSSTEEL 9FIAEROLASS F]1STEEL CUD WIFIAERGIASS REINFORCED PLASTIC <br /> Ion <br /> ETHNOL COMPATNLE FRPB. R 1� ❑ <br /> MATERIAL 14 F1 AER STEEL NOWN NRS BRONZE 95IRM <br /> F1I RUBRVI LINED 0 2 ALKYD LINING 3 EPDXf LINING ��4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING 6 UNLINED I_'�J 95 NOWN <br /> LINING <br /> ISUPNG MATDKAL OJ11rA11RlF MTH ID7A YET/Wgl7 YES 990R1EA <br /> D.CORROSION I POLYEIHLENE WRAP F1 2 TAR OR ASPHALT 3A WRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 GADK919ICPIIOTECHGN [-]91 NONE 95 UNKNOWN El 99 OTHER <br /> IV. PIPING INKOhMATI N CIRCLE A IF ABOVE GROUND, U IF UNOERGnOUNO,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A U SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A W5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEVIRON A U 2 STAINLESS91EEL A U 3 POLYVINYL CHI OTIME(PVC) A U d FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5ALUMINUM A 141 CONCRETE A U 7STEEL CLADW/hRP A U 610091 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A !11 6 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION Y TEM CIRCLE V Fon PRIMARY.OR 9 Fon SECONDARY,A PRIMARY LEAK bttECtION SYSTEM MUST BE CIRCLED. <br /> d IWSUAL CHECK Pd INVENfOTh'RECONCILIATION P 1 3VADOSE WELLS P d I ELECTRONIC MONITOR P A S GROUND WATER MONITORING WELLS <br /> P A PRECISION TESTING P 7 PBESSLIRETESTING P d 91 NONE 0 d 95 UNKNOWN P d 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I.ESTIMATED DATE LA USED(MONTH 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> ��IPh SUBSTANCE REMAINING IN ALLOHd INERT MATERIAL? El YES EjNO <br /> G <br /> THIS FORM HAS BEEN COMPL&ED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED d SIGNATURE) DATE <br /> r <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION A AGENCY N FACILITY Ib 139'021 TANK Ib N <br /> 3 � � E Fb <br /> CURRENT LOCAL AGENCY FACILITY 101 APPROVEDlYNAME PHONE A WITH AREA COPE <br /> G2.m G S 3 z <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK X PERMIT AMOUNT SUL iROI AMT. FEECODC RECEBY: <br /> I mo. <br /> roRMR(A-29_BA) THIS FORM MUST BE ACCOMPANIEU id A FACILITYISITE APPLICATION, FOR69 'A',UNLESS A CURREN F FORM'A' HASBEENFILED <br /> DATA PROCESSING COPY <br />