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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FOR El UNDERGROUND STORAGE TANK PROGRAM _ TANK PERMIT APPLICATION INFORMATION Qp TANK COMPLETE A BEPARATE NF FORM WITH THE FOLLOWING IATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑O RENEWALPERMIT 5 CHANCE OF INFORMATION ❑ 7 PERMANENTLYCLON ONE ITEM ❑ 2 INTERIM PERMIT ED AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED O? FACILITY/BITE NAME WHERE TANK IS INSTALLED: d .L,), �' Qi - - FABM TANK-YES E] NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK 101 0-3 1 8. MANUFACTURED BY: u C.YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: p O 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A CEl MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑0 DIESEL ❑0 CHEMICAL PRODUCT ❑1 00. I pgppUCT (USAHOL 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS 00 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ? METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A CAS 1 C.A.S.1: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C,A 0 A TYPE OF ❑21WALLED ❑0 SINGE WALLED WITH ExTEROR Loa ❑95 UNKNOWN SYSTEM 2 SI Al1ED ❑/SECONDARY CONTAINMENT ❑99 OTHER I SIEEUBON ❑2 STMSTMESSSTEEL ❑7 FIBERGLASS ❑1 STCIAO WIFIBE AASS REINFORCED"TC R.TANK MATERIAL 5 NNDFEIE ❑0 POLYVINYLCHLOROE ❑ 7 ALUMINUM ❑6 100%MEIFIANOL COMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I Man LINED ❑2 ING ❑S EPDXY LINING /PHENOIICUNNG LINING ❑SIXASSl96NG 6 UNLINED ❑95 UNKNOWN ❑SUM MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D,CORROSION ❑ I POLYEDIDEWRAP ❑2 T AFPFMLT ❑2 WN7L WRAP ❑ flBERGLLSSREINFORCED PLASTICPROTECTION ❑5 CARDDCPROTECT07N I NONE ❑95 UNKNO N 99 OTTER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 0 GRAVITY A U 91 NONE A 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 7 LINED TRENCH A U 91 NONE A _ 95 UNKN W U 99 OTHER A U I STEEL/ l A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAO W/FRP A U B IC 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 9 ( VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P 9 9VADOSE WELLS P 9 1 ELECTRONIC MONITOR P 5 GROUND WATER MONITORING WELLS PRECISION TESTING P 9 7 PRESSURE TESTING 9 P 6 95 UNKNOWN P t 99 OTHER V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANT(TY OFDALLONB 1 WAS TANK FRLED WITH / SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES O L1 � Cti// w ✓� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME IPRINTED A SIONAI URE) DATE LOCAL AGENCY USE ONLY COUNTY E JURISDICTION 1AGENCY# FACILITY ID 1 TANK ID! oz' '-_jyssI (' I I O oC) 51 CURRlNT LOCAL AGENCY FACILITY 11'01 APPROVED BY NAM! PHONE E WITH AREA CODE /-,->0/3/� b PERMIT NUMNIR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 1\yiCHECK F PERMIT AMOUNT ARGE AMT. FEF CODE 2l/Y 1 9Y SAl/