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ARD STATE OF CALIFORNI WATER RESOURCES CONTRO ., FORM `E3': UNDER ROUND STORAGE TANK PRO AM r ; TANK PERMIT APPLICATION INFORMATION a TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ARM TANK-YES NO 'FACILITY/SITE NAME WHERE TANK IS INSTALLED: un I. FCYEAR K DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SP IFY � CD B. MANUFACTURED BY: WNERS TANK ID 0 INSTALLED D. TANK CAPACITY IN GALLONS: © �� 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C. ❑ 1 UNLEADED 2 LEADED ❑ 3 DIESELA. MOTOR VEHICLE FUEL [:] 2 PETROLEUM El CHEMICAL PRODUCT F-14 OIL B11 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 ,/)_ C.A.S.#: _ HAZARDOUS SUBSTANCE STORED&C.A.S.k ,/� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I DO ALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELIRON ❑ 2 STAINLESS STEEL FIBERG AS5 ❑ 4 STEEL CLAD WIFIBERGUASSREINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑5 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ W OTHER 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLI LINING C. INTERIOR ❑ 6 UNLINED NKNOWN LINING ❑ 5 GLASSLINING ❑ IS LINING MATERIAL COMPATIBLE WITH100%MFTHANOL7 ❑YES ❑ NO �90THER D.CORROSION ❑!1,P LENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION FX5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER {V, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A U 9i NONE A U 95 UNKNOWN A U 99 OTHER A.SYSTEM TYPE A U 1 SUCTION A PRESSURE A U 3 GRAVITY B. CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE { 1�5 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 UCONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL. A1LUNKNOWN A U 99 OTHER EAK DETECTION SYSTEM CIRCLE PFF///_FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1 VISUAL CHECK (:>?S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MIDI ,/� 2- ESTIMATED REMAINING G I INERT MATERIAL? ❑YES [] NO rlj'I� SUBSTANCE REMAWING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# G ! o APPROVED BY NAME PHON #WITH AREA CODE CURRENT LOCAL AGENC CILITY ID k _ p' �/►� 2 PERMIT NUMBER PERMIT APPROVAL DATE PER IT EXP ATION DAT CHECK# PERMIT AMOUNT SURCHARGE AML FEE CODE RECEIPT# BY: - FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIMIFY A FACILITY/SITE TEAPPLICATION, ROCES PP, FO RGOPYA',UNLESS A RRENT FORM W MAS BEEN FILED