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s i ATE OF CALIFORNIA WATER RESOURCES CONTRO ARD FORMW:: UNDER ROUND STORAGE TANK PROM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK, o MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ONE ITEM 0 2 INTERIM PER MIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED'TANK 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE FACILITY/SITE NAME WNERE TANK IS INSTALLED: ❑8 TANK REMOVED S I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— FARM TANK-YES Lj NO SO Z SPECIFY •0 A. OWNERS TANK IDM CYEAR INSTALLED B. MANUFACTURED BY: u . D, TANK CAPACITY N GALLONS I1. TANK CONTENTSIF(A.1),IS MARKED,COMPLETE ITEM C.IF(ALI),IS NOT MARKED,COMPLETE ITEM A. [] 1 MOTOR VEHICLE FUEL E]2 P EUM D. 3 CHEMICAL PRODUCT OIL R' C. 0 1 UNLEADED 2 LEADED 3 DIESEL 0 5 HAZARDOUS 80 EMPTY []95 UNKNOWN Ej I PRODUCT 0 4 GASAHOL 5 JET FUEL E16 AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF � WASTE 7 METHANOL 9g OTHER(DESCRIBE IN ITEM D,BELOW) HAZARDOUS SUBSTANCE STORED&C.A.S.M W U 5 he zry % / 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D CA S. A TYPE OF ❑)LE WALLED E]3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM SING WALLED Ej 95 UNKNOWN 4 SECONDARY CONTAINMENT 99 OTHER B. TANK I STEEL/IRON 2 STAINLESSSTEEL El 3 FIBERGLASS E]4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE E]6 POLYVINYLCHLORIDE 7 ALUMINUM 9 BRONZE [] 10 GALVANIZEDSTEEL E] 95 UNKNOWN E]B 1 99 OTHER OTHER HANOL COMPATIBLE FRP C. INTERIOR ❑ I RUBBER LINED 02 ALKYD LINING ❑3 EPDXY LINING E14 PHENOLIC LINING LINING ❑ 5 GLASS LINING 6 UNLINED ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? UNKNOWN El YES F-1 NO F-1 99 OTHER D. CORROSION ❑ I POLYEIHLENE WRAP E]2 TAR OR ASPHALT PROTECTION 5 CATHODIC PROTECTION — ❑3 VIHY WARP 4 FIBERGLASS REINFORCED PLASTIC 91 NONE UNKNOWN �gg OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE a u 1 SUCTION U 2 PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED AA U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL p C. MATERIAL A U 5 ALUMINUM U 3 POLYVINYL CHLORIDE(PVC) A U 4100%METHAN L p A U 6 CONCRETE A U 7 STEEL CLAD W/FRP U 91 NONE A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U B 100%METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. L/- P S 1 VISUALCHECKS p INVENTORY RECONCILIATION 6 PRECISION TESTING P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 G P S 7 PRESSURETESTING P S 91 NONE ROUND WATER MONITORING WELLS �f S OP P S 95 UNKNOWN P S 99 OTHER— VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LA;:111 SED(MO/YRI 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3, WAS TANK FILLED WITH GALLONS INERT MATERIAL? E]YES [] NO avisFor7n.'yAseEE7y COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliilliillillillillillillillillillilliillillillillillillilliillillillillillillilliillillillillillillillillillillilliillillillillillillilliillillillillillillilliillillillillillillillillillillilliillillillillillillilliillillillillillillilliillillillillillillillillillillillilI CO)U�NTY%# JURISDICTION# AGENCY# `�--`iJ L= = FACILIMD /TAAJ�NK ID N CURRENTL NCY FACILITY IDM D "" APPROVED BY NAME w1�IJ PHONE M WITH AREA CODE P MIT NUMBER y7\� PERMIT APPROVAL DATE PEP IT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(s-29-88) THIS FORM MUST BEACCOMPANIEt,. AFACILITY/SITE APPLICATION, FORM -Pk' -',UNLESSA ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY