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:STA { t OF GAL R-UHNIA WATER RESOURCES CONTROL BOARD FeNm `B': UNDP ;ROUND STORAGE TANK PRC „4AM ' �/�N TANK .-ERMIT APPLICATION INFORM... ION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ® 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY LO / K ONE ITEM 11 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �C 8 TANK REMOVED ) Y FACILITY/SITE NAME WHERE TANK IS INSTALLED: civ ^ 6TM�T�A�NK - YES ❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS- IF UNKNOWN -SO SPECIFY % / z/_1 A. OWNERS TANK ID It CZp B. MANUFACTURED BY: Xerxes C. YEAR INSTALLED 1990 D. TANK CAPACITY IN GALL -CNS: 10, 000 11. TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. A. 1 MOTO1 VEHICLE FUEL n 2 PETROLEUM B. C. [_y 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS El 80 EMPTY [:]95 UNKNOWN ❑ 2 WASTE 7 METHANOL ❑ 99 OTHER (DESCRIBE IN ITEM D, BELOW) D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS HAZARDOUS SUBSTANCE STORED & C.A.S. # B. TANK C.A.S. #: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A, B, C, & D A. TYPE OF❑X 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER _ B. CONSTRUCTION 1 STEEUIRON ❑ 2 STAINLESS STEEL ® 3 FIBERGLASS ❑I 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10096 METHANOL COMPATiBLE FRP MATERIAL 9 SFONZE ❑j 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER FIBERGLASS PIPE A U 91 NONE ❑ 1 RUBBER LINED F-12 ALKYD LINING F-]3 EPDXY LINING ❑ 4 PHENOLIC LINING C LINING R ❑ 5 GLASS LINING ❑ 6 UNLINED 8 100% METHANOL COMPATIBLE FRP ❑ 95 UNKNOWN A CIIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? ]X YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TARORASPHALT ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION n 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A© 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A 04 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100% METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 S 1 VISUAL CHECK P(p 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER Red Jacket PLD VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DA -i E LAST USED (MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH L— N /A I SUBSTANCE REMAINING IN N/A GALLONS INERT MATERIAL? N/A D YES ❑ NO FHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLIGIN NAME (PRI E BSI ATURE,)) / Frances W. Hedric DATE Agent for ARCO Barghausen Consulting Engineers, Inc. (916) 348- 305-1 LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # AGENCY # [IN CURRENT LOCAL AGENCY FACLLiTY ID # PERMIT NUMBER FACILITY ID # a, U O 1 (""'� APPROVED BY NAME PERMIT APPROVAL DATE PERMIT EXPIRATION DATE TANK ID # FZf-o I / I e PHONE # WITH AREA CODE � !`NL/`K tl uep�/IT A•.I L111yT I aoln I rSr nn�n iwn I w FORM B (a-2,-aai THIS FORM MUST BE ACCOMP;-.....O BY A FACILITY/SITE APPLICATION, FORM 'A', UNLEz.o A CURRENT FORM'A' HAS BEEN FILED