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r STATE OF CALIFOR& WATER RESOURCES CONTRAOARD <br /> FOFWIB t 1 17" 1 UNDERGROUND STORAGE TANK P OGRAM #91452A <br /> F N tt r!_ TANK PERMIT APPLICATION 1 RMATION <br /> - cGRNIPL��E A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. <br /> �II <br /> MARK ONLY I NEW PERMIT XO 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PERMANENTLY D TANK <br /> ONE ITEM F] 2 INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE <br /> FACILITY/SITE NAME WHERE TANK 18 INSTALLED: BTII Parks Chevron FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY <br /> A. OWNERS TANK ID# WC5720C B. MANUFACTURED BY: ------ <br /> C. YEAR INSTALLED 1969 D. TANK CAPACITY IN GALLONS: 10,000 gallons <br /> 11. TANK CONTENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ® I MOTOR VEHICLE FUEL 2 PETROLEUM B. C. Ell UNLEADED 0 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 1 OIL Q 1 PRODUCT [j 1 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN ❑2 WASTE ❑T METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.M C.A.S.#: 8006619 <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,E o <br /> A TYPE OF ❑ 1 DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTEROR LINER 95 UNKNOWN <br /> SYSTEM ©2 SINGLE WAUED ❑d SECONDARY CONTAINMENT 99 OTHER <br /> El 1 STEELIIRON ©2 STAINLESS STEEL Ej 3 FIBERGLASS /STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> I RUBBER LINED 2 ALKYD LINING E]3 EPDXY LINING /PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING ©6 UNUNED ❑95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH lW%METHANOL? DYES El NO El99 OTHER <br /> D.CORROSION ❑� 1 POLYETHLENE WRAP [:]2 TAR OR ASPHALT 1:13 VINYL WRAP ❑A FIBERGLASS REINFORCED PLASTIC <br /> F] <br /> PROTECTION t l 5 CATHODIC PROTECTION E] 91 NONE ❑95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION AU 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION 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 <br /> A U 1 STEEL/IRON 4 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE INC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CUD W/FRP A U 8 10096 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P f 1 VISUAL CHECK u 8 2 INVENTORY RECONCILIATION P f 3 VADOSE WELLS P S <ELECTRONIC MONITOR P f 5 GROUND WATER MONITORING WELLS <br /> 8 6 PRECISION TESTING P 8 ) PRESSURE TESTING P f 91 NONE P 8 95 UNKNOWN P f 99 OTHER_- <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OF GIM10Nf 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIALP YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PEN ERI TO,T S OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE <br /> OMIT (,-- SolFrlSo <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# ADEN CY# CILITY ID M TANK ID R <br /> m <br /> CURRENT LOCAL AGENCY FACILITY ID I APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT WRCHARGE AIR. FEE CODE RECEIPT BY: <br /> FORMB(8-29-88) THISFORMMUSII AFAarrynmRn=K FORM'A' CUMT FIMW HNISEENFKED <br /> 1 3 1"covr DPRE <br /> I <br />