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SPATE OF CALIFORN1.5_. WATER RESOURCES CONTROL BOARD •':.�:,'h. FORM 18% UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION " COMPLETE A SEPARATE FORM WITH THE FOLLOWIN HFORMATION FOR EACH TANK. a '" MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED rl� r �9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: `�' / ARM TANK-YESO ❑ I. TANK DESCRIPTION COMPLETE ALL.ITEMS-IF UNKNOWN—SO SPECIFY 3 EC OWNERS TANK ID# B. MANUFACTURED BY: 00 YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS 5 HAZARDOUS 80 EMPTY UNKNOWN ❑2 WASTE ❑7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL-ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# C.A.B.#: I` Ill. TANK CONSTRUCTION MARK ONE LT A ONLY IN BOIL A,B,C,&D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLEWAILEDWITTIDCTERIORLINER 95 UNKNOWN SYSTEM ❑2 SiNGLEWALLED 4 8ECONDARYCONTAINMENT 99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STETS ❑3 FIBERGLASS ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLTOM CHLORIDE ❑T ALUMINUM ❑8 100%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑10 GALVANIZEDSTEEL UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBW UNE] ❑2 ALKYD UNING 3 EPDXY LINING ❑4 PWMCUNING LINING ❑5 GLASS LINING ❑6 UIdm 5 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑99 OTHER D.CORROSION ❑ I POI.YETHLENEWRAP ❑2 TARORASPHALT ❑3 V!VYLWRAP ❑4 FIMRGiASSREINFOMMPLASTIC PROTECTION ,❑5 CATHODIC PRoTECTION 91 NONErl?oj�'uwNowN ❑99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, l,) IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A M96 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNED TRENCH A U 91 NONE A 95 UNKNOWN A U " 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 CONCRETE' A U 7 STEEL CLAD W/FRP A U 0 100%METHANOL COMPATIBLE FRP A U 9 GALVAN4ZEDSTEEL A U 5 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P $ 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES NO 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 ID!# TANK ID �'# Ho: 14 ( lJ tf k [CHECK# RENT LOCAL AGENCY FlyplLtyl(l _tl� n�� APPROVED BY NAME PHONEY WITIi AREA CODE MITNUiiIBER �ff 7j/'!�(`/fJ,�IJrC PERMiTAPPROVAL DATE f+ERM1TEXPIRAItONDATE' PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 45Y: J r FORM B(6.29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SRE APPUCArON, FORM`A',UNLESS A CURRENT FORMA' HAS BEEN FILED 13ATA PROCESSING COPY