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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM TANK G TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING,21IFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT - k:EMW TANK CLO RE 8 TANK REMOVED O qj FACILmYSME NAME WHERE TANK 19 INSTALLED: Port of Stockton Food Dist , AM TANK-TEE❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN I B. MANUFACTURED BY- unknown C. YEAR INSTALLED Unknown 10. TANK CAPACITY IN GALLONS: 5000 11. TANK CONTENTS IF(AT),16 MARKED,COMPLETE ITEM C.IF(At).IS NOT MARKED.COMPLETE ITEM D. A. ® I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ®3 DIESEL ❑3 CHEIAICAL PRODUCT E]A OIL ©1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS E]5 HAZARDOUS [—]BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOR A.B,C.A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH E GEROR LINER ❑%UNKNOMI SYSTEM ®2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑M OTHER ® I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑M STEEL CLAD WIFIBERGLASS REINFORCEDPLASTIC B.TANK ❑5 CONCRETE ❑6 PO-WNYL CHLORIDE ❑7 ALUMINUM ❑6 tOD6 METHANOL COMPATIBLE FRP MATERIA( ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER UNED ❑2 ALM UNING ❑3 EPDXY LINING ❑A PHENOLIC UNING C.WRERIOR 5 GLASS LIMNG6 UNLINEDUNDI(7ATI NED 95 LWIIMO ❑ ® ❑ ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I Pt7LMHUNE WRAP ®2 TAR OR ASPHALT ❑3 VIM WRAP ❑A FIBERGLASS REINFORCm PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE • U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U "OTHER B.CONSTRUCTION A Y 1 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 Q 1 STEELRRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCIADW/FRP A U 8100%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 8 1 VISUAL CHECK oP 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S A ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED GUANTITY OFDALLONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E]YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTYM PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE Randy Thomas LOCAL AGENCY USE ONLY COUNTY F JURISDICTION I AGENCY F FACILITY 10 E TANK ID N ® = = I ol o I TTF77t I v I v I v 19 CURRENT LOCAL AOENCT FApLrtY ID 0 AM110Ko 8r NAM[ PHONE N WRN""co" PEPIMIT NUMBER PERMIT APPROVAL DATE PERMIT EEPMIATIOII DATE /(J—1-g a cmm P PEAMIT AMOUNT 8 IMIRDE Arr. PEE COOS RlCeIR F \ FOAMB(e29281 TMSFORMMUSTNACCONPNMIYAFACLRYOMMPJUMK FORM'At,UMEF"�CwAmff PM-A' IMBEFNFKF�IDD 1 DAA"PROCESSING COPY 2 LOCAL AGENCY C604 3 ME COPY