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STATE OF CALIFOR.._ A WATER RESOURCES CON". 01. BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM , TANKTANK PERMIT APPLICATION INFORMATION COMPLETE:A IEPAAATS PORM WITH TNS POLLOWINO 1 "MATION FOR EACH TANx. ^�•' MARK ONLY ❑ I NEW PERMIT ❑S RENEWAL PERMIT, CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ! ONE YTEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE ❑B TANK REMOVED G1 FACILITYAi1Tt MAYS YFNERE TANK II INSTALLED: _) T-'/'P ire c- it FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNER(TANK IDS ,i// B. MANUFACTURED BY: �/k-- CT C. YEAR INSTALLED -`K— D. TANK CAPACITY IN GALLONS: 000 11. TANK CONTENTS IP(111),IS MARKED,COMPLETE ITEM C.If(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 041 MOTOR VEHICLE FUEL ❑2 PETROLEUM B C. ❑ 1 UNLEADED 2 LEADED ❑ G DIESEL ❑9 CHEMICAL PRODUCT El OIL PRODUCT EJ1 GASAHOL E)5 JET FUEL ❑8 AVIATION GAS ❑5 HAZARDOUS E]10 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 1 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BEl DW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.N C.A.S.N: Ill. TANK CONSTRUCTION MARK ONt ITEM ONLY IN SOK A.B,C,A D A TM OF ❑I WMLW ❑5 SINGLE WALLED MTH 00011011 LINER ❑95 UNKNOWN SYSTEM [312�9011WAUJEO ❑1 SEOOIOARYCONTOMW ❑99 OTHER -- I STER/INON ❑2 STAINLESSSIEEL ❑S FIBEINILASS ❑ 1 STEEL CLAD W/FIREROUSS REINFORCED PLASTIC I,TANK ❑5 CONDIM ❑I POLYVINYL CHLORIDE ❑ 7 ALUTAl1AA1 ❑A IOOR METHANOL COMPATIBLE FRP MATERIAL ❑!BIDN2E ❑ 10 OALVAMIED STEEL ❑%UIMITOAM ❑99 OTHER ❑1 RIBBED LNM ❑2 ALKMLNNO ❑I EPDXY LNNG ❑ 1 ICLNNG C " ❑S GAsstxN9G ❑I UNUNEO NUMN ❑15 L1MIN)MATERIAL CDWATNEE MTM IW%LIETHANOL7 ❑YES ❑NO ❑99 OTHER D.CORROMON ❑1 POLYETHLEN W W ❑! OII ASPHALT ❑!VOM WRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CLTTIODICPRDTECTTON91 NOW ❑95 uww m ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I STICTION A U 2 PRESSURE A U G GRAVITY A U 91 NONE A I.CjA UNK ET 99 OTIIER M CONtTRI1CTI0N A91NGlE WALLED A U 2 DOUBLE WALLED A U B LINED TRENCH A U 91 NONE A U BS UNKNOWN A U MOTHER A f4/ A U 2 STAINLESSSIEEL A U S POLYVINYL CHLORIDE TPVC) A U 1 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A LUMINUM A U (CONCRETE A U 7 STEEL CLAD WEEP A U 9 100%METHANOLCOMPATtOLE FOP A U 9 GALVANIZED KEEL 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 I ( VISUAL CHECK P S 2 NAENTORY RECONCILIATION P 19VADOSE WELLS ► e ILiC MONITOR P 9 50ROUNDWATERMONITORINGWFLLS S I PREC1910N TE9TIN0 I S I PRE9HURE TESTING ► 1 BI NONE P j B6 UM(NOWN P I 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L E9TIIMTED DATE LAM USED(MO/YR) 2. ESTIMA7EDOUANTITY OFS. WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONI INERT MATERIAL7 DYES ❑NG THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPMANT'8 NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY US ONLY COUNTY E JURISDICTION I �AGE�NCY Nn FACILITY ID N TANK ID I = I�L�J c, / / '/ C% U ( l I- CVIIRENT LOCAL AOENCT FACKITY NII APPROVED NY NAME PHONE N WITH AREA CODE PERIM NUM9ER P[RMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I KRYff AYOVMT "IRCHAROl AMT. FEE COD[ :EIPTI v FDrIMeN2e9R THNFORMMUITIEACCOMPANIED[TAFACILmnITEAPPLICA?IOK FORM 'A',UNLESS A CURRENT FORM'k HASBEENFILEO