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STATE OF CALIFORNIA- WATER RESOURCES CONTROL ARD FORM `BERt,ROUND STORAGE': UND y£.� s GE TANK PROM TAN { TANK PERMIT APPLICATION INFORMATION �� �a. I COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OFlNFORMATION 4 ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 7 PERMANENTLY C SE K ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED [;ZM ME WHERE TANK IS INSTALLED: ' FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN —SO SPECIFY ^�I [A. OWNERS TANK ION �� B. MANUFACTURED BY . YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 10 Q00 If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL PETROLEUM 6. C. ❑ 3 CHEMICAL PRODUCT d OIL ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL �pROOUCT ❑ 4 GASAHOL ❑ JET FUEL ❑ 5 HAZARDOUS ❑ 6 AVIATION GAS 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑? METHANOL g9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /J, HAZARDOUS SUBSTANCE STORED&C.A.S.# [�,L,l�'J �� C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑95 UNKNOWN ❑99 OTHER B.TANK �1 'CONCRSTEEL/ETE ❑2 STAINLESSSTEEL ❑3 RBERGLASS ❑4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE 0 7 ALUMINUM ❑8 IGO%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING �6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 180%METHANOL? ❑YES ❑ NO [ g OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION F—] 5 CATHODIC PROTECTION ❑ 91 NONE a UNKNOWN 0 99 OTHER IV. PIPING INFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A i 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 U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A 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/FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A A U 99 OTHER U 8 100%METHANOL COMPATIBLE FRP V LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATE DATE LAST USED(MO/YR) 2. ESTIMATED O ANTITY OF SUBSTANC E AINING VN 3. WAST K FILLED WITH GALLONS IN R ERIAL? ❑ YES ❑ No THIS ORM HAS BEEN COMPLETED UNDER PENALTY OF ERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT. APPLICANT'S NAME(PAINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JUR[jEISDICTION# AGENCY# FACILITY ID# TANK ID# � ? o CUR R T LOCAL ApE CY FACILITY ID N L[1] APPROVE@ BY NAME '" PHONE ft WITH AREA CODE PER IT NUMBER �R` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 8 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT If BY: ECRM B(6-29-88) THIS FORM MUST BE ACCOMPANIED ACILITYISITE APPLICATION, FORM `A',UNLESS A C0n.; NT FORMA' HAS BEEN FILEO DATA PROCESSING COPY `J