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STATE OF CALIFORNiih WATER RESOURCES CONTRq&OARD FORM `R': UNDROU NDSTORAGE ANK PR PROGRAM " T TANK PERMIT APPLICATION INFORMATION ° TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: lr (�I ARM TANK - YES ❑ NO ❑, I. TANK DESCRIPTION COMPLETE ALL ITEMS - IF UNKNOWN - SO SPECIFY A. OWNERS TANK ID # 8. MANUFACTURED BY: C. YEAR INSTALLED O. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF (A.1). IS MARKED, COMPLETE ITEM C. IF {A.1}, IS NOT MARKED, COMPLETE ITEM D. A. D 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL }i# -PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF HAZARDOUS SUBSTANCE STORED & C.A.S. p C.A.S. #: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C,& D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM L2 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT U 1 SINGLE WALLED A U 2 DOUBLE WALLED ❑ 99 OTHER U 3 LINED TRENCH A ?95 UNKNOWN A U 99 OTHER o'f STEEL/ IRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1OD%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ® 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER U 99 OTHER F-]1 RUBBER LINED ❑ 2 ALKYD LINING F-]3 EPDXY LINING E]4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING ®'6 UNLINED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑ YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION �91 NONE ❑ 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A ?95 UNKNOWN A U 99 OTHER PERMIT NUMBER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP FEE COD A U 9 GALVANIZED STEEL A (�)95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P�B PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1 _ ESTIMATED DATE LAST USED (MO/YR) 2, ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑ YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED& SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY # E�l JURISDICTION # I I I I AGENCY # EI I I FACILITY ID # I o I IV 1611 TANK ID # 16110161- 5 CURRENT LOCAL ALGENCY FACILITY ID # APPROVED BY NAME v PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT PI TI N DATE CHECK # PERMIT AMOUNTSURCHARGE AMT. FEE COD RECEIPT # BY: FORM B (3-7-88) THIS FORM MUST BE ACCOMPANIED ETi A FACILITY/SITE APPLICATION, FORM `A', UNLESS A CMRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY