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STATE OF CALIFORiV1A WATER RESOURCES CONT•BOARD FORM IB1. UNDERGROUND STORAGE TANK PROGRAM +y ' -/n TANK >- .TANK PERMIT APPLICATION INF ATtON •�: COMPLETE A SEPARATE FORM WITH THE FOLLOWINIJWORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑D RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED �� FACILITY/SITE NAME WHERE TANK 18 INSTALLED: Z LS 360 .3. `j c�c,�fo,�y. FARM TANK•YES❑ NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A OWNERS TANK 10/ p / B. MANUFACTURED BY: a/c- C. CC.YEAR INSTALLED N/C D. TANK CAPACITY IN GALLONS: -7OL 11. TANK ONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. EE1I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑ S CHEMICAL PRODUCT ❑1 OIL T PROp(KT ❑1 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO EMPTY �95 UNKNOWN ❑2 WASTE 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.I CA.S.E: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOL(A.B,C.A D A TYPE OF ❑ I DOUBLEWALLED ❑O SINGLE WALLED WITH EXTERIOR LINEA Ell 95 lXdOl(7YIN SYSTEM 2 SINGLE WALLED /SECONDARY CONTAINMENT ❑99 OTHER S.TANK ❑ 1 SIEFUBON ❑2 STAINESS STEEL ❑ 2 FIBERGLASS ❑ 1 STEEL GAD W/FIBERGLASS REINFORCED"TIC MATERIAL ❑5 CONL7iETE ❑I POLYVINYL CHORDE ❑ 7 ALUMINUM ❑I IBO%METNWOLGOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL %UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBERLBIED 2 ALKYO LINING ❑G EPDXYUNNO ❑ 1 PHENOLIC UMNG LINING ❑5 GLASS LUNG ❑I LMNED / ❑95 UNKNOWN ❑ SUNNING MATERLIL COMPATIBLE WITH 100%METFLVKIL7 El YES ErNO C]99 OTHER D. CORROSION ❑ I POLYEIIEEW WMA 2 TAR ORASPHALT ❑2 WNYLWRAP ❑ /FIBERGLASS REINFORCED RASTIC 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 I SUCTIO A U 2 PRESSURE A U D GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U 0 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U NKNOWN 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 B ( VISUAL CHECK P B 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P B 1 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P B. /PRECISIONTESTINO P B 7 PRESSURE TESTING ► 1 ON P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED IMO/YR) 2. ESTIMATED QUANTITY OF I,-WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:)YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION/ �AGE�NCY En FACILITY ID/ TANK ID/ 3 9 "--.1 -1 L.LLJ 0 1 o I �- I ° I / I --- L 0 I D I o 121 CURRENT LOCAL AGENCY FACILITY 10/ APPROVED BY NAME PHONE 1 WITH AREA CODE Z—D - PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ p(gy1T AMOUNT URCHAgOE AMT. FEE CODC ECEIP71 BY: