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STATE OF CALIFORNI.o.,t ' WATER RESOURCES CONTROL BOARD FORMV:: UNDERGROUND STORAGE TANK PROGRAM e TANK PERMIT APPLICATION INFORMATION r '' TANK , COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. `" °^"' i I C1 MARK.ONLY 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El PERMANENTLY CLO I` ❑ 1 NEW PERMIT ❑ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE ❑8 TANK AEMOVEDE FACILITY/SITE NAME WHERE TANK IS INSTALLED: C14ARM TANK-YES NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN-90SPECIFY � A. OWNERS TANK ID# B. MANUFACTURED BY: C.YEAR INSTALLED 4/5� D. TANK CAPACITY IN GALLONS: E 11. TANK CONTENTS . IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. G. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ BO EMPTY [D UNKNOWN ❑2 WASTE ❑ 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D.BELOW) 5 HAZARDOUS El D.IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED"L7(ROR UNER UNKNOWN SYSTEM ❑2 S4NGLE WALLED ❑4 SECONDARY CONTAINMENT In 99 OTHER ❑ I UEUIRON ❑2 STAINLESSSrHL ❑3 RBERGASS ❑4 STEEL CLAD W/RBEAGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL ORORIDE n y q AINUM ❑B 100%METHANOL COMPATPBLE FRP MATERIAL ��§/ - ❑9 BRONZE ❑ 10 GALVANIZEDSTEEt 5 UNKNOWN ❑M OTHER [:] I RUBBER UNED E]2 ALKYD UNING ❑3 EPO%YLINWG ❑4 UC UNING LIKING C.INTERIOR 5 GLASSUNING El 6 UNLINED EP4UNKNOWN ❑IS UNING MATERIALCOMPAT18LE WITH IW%MEfF{ANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT 3 M(LWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECnm ❑9s NOPE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF A80VE GROUND, U IF UNDERGROUND,DOTH IF APPLICABLE { AL SYSTEM TYPE A U 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 95 UNKNOWN A U 99 OTHER A U i 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 CLADW/FRP A U 9 100%METHANOLCOMPATIBLEFRP A U 9 GALVANIZED STEEL A U 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 8 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P $ 91 NONE P B 95 UNKNOWN P S 99 OT14ER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON$ INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE;1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY I COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 10101 dl- 11-7 L/ ' 101 .0 0 14 CURRENT L00r;�1(F/1�IT 7 APPROVED BY NAME PHONE a WITH AREA CODE PERMIT NUMBER �(�f{,rV 1�� I/ PERMIT APPROVAL DATE PERLNI7 EXPIRATION DATE (� CHECK E PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT at BY: j FORM 6(6-29.89) THIS FORM MUST BE ACCOMPANIED BY A FACR.i RITE APPLICATION, FORM`A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY