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STATE OF CALIFORNI f§ WATER RESOURCES CONTR4kARD <br /> FORM T' UNDERGROUND STORAGE TANK PROGRAM 11 <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY -.❑ I NEW PERMIT E 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLYCLOSED�NK7 <br /> ONE ITEM 2 INTERIM PER /AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 6 TANK REMOVED <br /> FACILITY/81TE NAME WHERE TANK IS INSTALLED: �C� M�. �• RM TANK-YES NO N <br /> / "7 .� <br /> I. TANK DESCRIPTION COMPL EALL ITEMS-IF UNKNOWN-80 SPECIFYO <br /> co <br /> A OWNERS TANK IDM L!- B. MANUFACTURED BY: <br /> CD <br /> C. YEAR INSTALLED ! ;� D. TANK CAPACITY IN GALLONS: CJ <br /> Ii. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(Al),IS NOT MARKED,COMPLETE ITEM D. <br /> A 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C.Ti 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT /OIL ©j PRODUCT /GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> S HAZARDOUS ❑BO EMPTY 95 UNKNOWN F 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 CA.S.M <br /> C.A.S.p: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D <br /> A TYPEOF0 OUBLE WALLED 3 SINGLE WALLED WITH EXISW UNER �95 UNKNOWN <br /> SYSNGIEWALLED 1 SECONDARYCONTAINMENT 99 OTHEA <br /> S.TANTEEUYiON ❑2$iMNLE55STEEL ❑3 fIBEAGUSSE]/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATE ❑6 POL51W"I'LORIDE 7ALUMINUM B 100%METHANOL COMPATIBLE FRP <br /> RONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR ❑ I RUBBEALINED 2 ALOD UNING 03 EPOAYUNNG 1 PHENOLIC LINING <br /> LINING ❑5 G%UMLNNG 6 LNUNFD 95 UNKNOWN <br /> IS1AING MATERIAL COMPATIBLE MTH IW%METVNGL7 E]YES [:]NO E]99 OTHER <br /> D.CORROSION ❑ I POLYETHIFHEWRAP 2 T:AR El 3 VINYL WRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION: 5 GTHODIC PRDTECTION 91 HONE El 95 UI j"N 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> I A SYSTEM TYPE A U 1 SUCTION M- -- <br /> PRESSURE EWEIM YA U 91 NONE A U 95 UNKNOWN A U 99 OTHERB.CONSTRUCTION A U I SINGLE WALLED DOUBLE WALLEDRENCH A U 9I NONE A U 95 UNKNOWN A U 99 OTHERA U 1 STEELARON STAINLESSSTEELNYL CHLORIDE(PVC) A U / FIBERGLASS PIPE A U 91 NONEC.MATERIAL A U 5 ALUMINUM CONCRETE LAD W/FRP A U B 100%METHANOL COMPATIBLE FRPA U B GALVANIZED STEEL UNKNOWN <br /> V. LEAK DETECTION SYSTEM CIRCLE FPRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 6 1 VISUAL CHECK p S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 1 6 PRECISION WRTINU P i I PRESSURE TESTING P S 91 NONE P / 96 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 7.WAS TMATERIAL?ANK FILLED WITH <br /> GALLONS INERT MATERIALS �YES El NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, <br /> APPLICAM'S NAME(PRINTED 6 SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY/ <br /> = FACILITY ID Y TANK 10 Y <br /> CURRENTLOCAL AOERCYFACIUTY 101 <br /> APPgOYEO BY NAME PHONE/WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION OATS p <br /> CHECK 1 PERMITAMOUNT �RCHARGE AMT. FEE CODE o- <br /> - EIPTI SY: <br /> i,,� FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A' UNLESS A CURRENT FORMA' HAS BEEN FII Fn <br /> d <br />