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/% WATEsOAvtu R RESOURCES C K PROGRAM � a STATE OF Cp►LIFORI . .: UND9RGROUND STORAATION FORMATION AcH TANK. FORM `s,: TANK PERMIT APPLIC OF INFORMATION ❑7 PERMANENTLY CLOSEDK K COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION TAN 5 CHANGEB TANK REMOVED f 3 1 NEW PERMIT 3 RENEWAL PERMIT g TEMPORARY TANK CLOSURE 13MARK ONLY 4 AMENDED PERMIT ❑ FARM TANK-YES❑ NO ONE ITEM El INTERIM PERMIT y FACILITY/SITE NAME WHERE TANK IS INSTALLED: = XN NOWN�SO SPECIFY i. TANK DESCRIPTION COMPLETE ALL ITEMS IF U B MANUFACTURED BY'. A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: r ` C.YEAR INSTALLED If{A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED,COMPLETE ITEM PLEADED DIESEL 11. TANK CONTENTS e C. 1 UNLEADED ❑g AVIATION GAS ❑ A. Ort MOTOR VEHICLE FUEL ❑2 PETROLEUM 4 GASAHOL E]5 JET FUEL PRODUCT E]3 CHEMICAL PRODUCT C]4 OIL 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM 0,BELOW) F-1 5 HAZARDOUS + 1.4 EMPTY ❑95 UNKNOWN ❑2 WASTE C.A.S.#: D. IF NOT MOTOR HAZARDOUS SUBSTANCESTOREDSTORED&C.A.S. OF III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D El UNKNOWN ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER A TYPE OF ❑99 OTHER SYSTEM 2 SINGLE WALLED E]4 SECONDARY CONTAINMENT STEELIIRON E]2 PAINLESS STEEL ❑3 FIBERGLASS 0 4 STEELCLADWlFIBERGLASSREINFORCEDPLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM 6 100%METHANOLCOMPATIBLEFRP F-1 MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER Fl 02 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING 1 RUBBER LINED � 95 UNKNOWN C.INTERIOR F-15 GLASSUNING 21 1"UNLINED LINING IS LINING MATERIAL COMPATIBLE WITH 100°6 METHANOL? L]YES E]NO 99 OTHER F-11 POLYETHLENEWRAF 7AR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION � 5 CATHODIC PROTECTION 91 NONE El 95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i 1 SUCTION A U 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 U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE Ar595 UNKNOWN A U 99 OTHER ! p U t STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 F18ERGLASS PIPE A U 91 NONE / C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADWIFRP A U B 100%METHANOLCOMPATIBLEFRP A U 9 GALVANIZED STEEL A�95 UNKNOWN A U 99 OTHER CrRCtED. V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUSTB>: P S 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELL �� P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 110 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2. ESTIMATED QUANTITY OF S.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN INERT MATERIAL? �YES �NO p h GALLONS J '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# JURISDICTION# AGENCY# FACILITY 10# TANK ID# 2L CURRENT LO AGENCY FACT,ITV IDM APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE ERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM IN,UNLESS A CURRENT FORMA' HAS BEEN FILED . FILE COPY