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STATE OF CALIFORNI WATER RESOURCES CONTR BOARD FORM 48T UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION % •`COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK Z I s MARK ONLY I;;; W PEAMfT ❑3 RENEWAL PERMIT ❑ 5 CKWGEOFINFORMATION ❑7 PERUANENTLYCLOOSgU4K`- ONE ITEM 1 1ERIM PERMIT ❑ 6 AMENDED PERMIT. ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVEDFACILITY/SITE NAANK 181H6TALLED: FARMTANK-YES❑ NO (�] Ir TANK DESCRIPTION COMPIoiETE ALL ITEMS-IF UNKNOWN-60 SPECIFY C-d A OWNERS TANK ID 1M e. MANUFACTURED BY: (� C.YEAR INSTALLED41g 0. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1), ARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUMS. C. I UNLEADED ❑ 2 LEADED ❑3 DIESEL r73 CHEMICAL PRODUCT ❑6 OIL ) pRpp(kT ❑/ GASANOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS - ❑ 50 EMPTY ❑95 UNKNOWN ❑ Z WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ''nn p HAZARDOUS SUBSTANCE STORED L CAS.1. 5 f-}\. � CAS.6: Fv 0 D Z�o16 111. TANK CONSTRUCTION MARK ONEITEM ONLY IN BOXA,B,C,DD . . A TYPE OF• . ❑1.000BIE wALLm ❑3 SINGLE WALLED WITH ExTF1BOR UNER ❑95 UNKNOWN SYSTEM :.' ❑2 SINGLEWAUM ❑1 SEWNOAM CDKTAINMFNT ❑99 OTHER ❑ 1 sTFELI6IDN ❑2 STAINLESS STEEL ❑ 3 FIBFRGIASS ❑1 STEEL DADwjFSEAGASS REINFORCEDPUSTIC S TANK. MATER" ..,❑5 DOIIMIE ❑6 POLYVRMOLOI60E ❑ 7 MUUKW a 11009METHANOLCOMPATIBLEFHP ❑ .; .9 BRONZE - C] 10 GALVMIIZEO STEEL CD UNKNOWN 99 OTHER C.INTERIOR .O 1 RUBBER LINED .. ❑2 AM ❑3 EPDXY U" ❑ A PHFNOUCUNNG LINING,: . ; ,;❑ g c LSS LBBNO ❑/ulx)Nm r795 UNKNOWN '❑IS LINING MATMLCOMPATBLE WITH 1009 MEIIWIOL? ❑YES ❑NO ❑99 OTHER 0.CORROSION . ❑ I aYETHLEAEWRAP .. ❑ 2 TAR ORASPRLLT ED3 VINYLWRAP ❑ BBGlA95 Fl1EWFORCED PIASIIC PROTECTION ❑S GODC TMPROTECTION ❑91 NONE ❑ 95 Uwma ❑99 OTHER IV, PIPING INFORMATION CIRCLE IF ABOVE GROUND. U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE - A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A u I SINGLE WALLED A U 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C•MATERIAL. A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U B ROY METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 96 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 t I VISUALCHECK P t 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P S 4 ELECTRONICMONITGR P t 5 GROUND WATER MONITORING WELLS F t 0 PRECISION TESTING P t 7 PRESSURETESTWO P 6 91 NONE P t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY Of PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY t ' : '.JURISDICTION O AGENCY t FACILITY ID/ TANK ID t 1 10151 CUR RENT LOCAL AOENCYfACILITV ID 6 / APPROVED BY NAME PHONE 0 WITH AREA CODE •v v 1 PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE _ to -y�K4 CNECNI PERMITAMOUNT �P 6UACHAIIGE AMT. FEECODE ECEIPT1 B7: 120 --`•A, •- FORMB(t•29•M) THIS FORM MUST BEACCOMPANIED BYAFACIUTY/SITE APPLICATION, FORM 'A'.UNLESS ACunneur Pnnuv NIC RIC.[II In