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STATE OF CALIFORNID WATER RESOURCES CONTRO&ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM #96465C .lu i3 TANK PERMIT APPLICATIO COMPLETE A SEPARATE FORM WITH THE FOLLOWI I b TANK �ANK. MARK ONLY 1 NEW PERMIT [33 RENEWAL PERMIT ❑5 CHAN6ESAAJ UU r?TKtin I ❑7 PERMANENTLY CLOSED TANK ONE ITEM El INTERIM PERMIT ❑A AMENDED PERMIT 6 TEMPIORfARRY�TANK CLOSURE B TANK REMOVED b FACILITY/SITE NAME WHERE TANK 18 INSTALLED. 5Pershing FARM TANK-YES❑ NO I . I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—BD SPECIFY A. OWNERS TANK ID# WC7706CB. MANUFACTURED BY: OWDT C. YEAR INSTALLED 1988 1D. TANK CAPACITY IN GALLONS: 10.000 gallo II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. © 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑0 OIL ® 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.R C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,S,C,A D A TYPE OF ®1 DOUBLEWALFD ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED MASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑A PHENOLIC LINING C.INTERIOR LINING ❑5 GLASSUMNG ❑6 UNWED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPIULT ❑3 VINYL WAP ❑A 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 A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A 04 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8/00%METHANOLCOMPATIBLEPIIP 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 1 VISUAL CHECK P©2 INVENTORY RECONCILIATION P N 3 VADOSE WELLS OB 0 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO7YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONt INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN THE EST KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED b SIGNATURE) DATE to L SoVA Sort Lj- 0- 90 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N AGENCY F FA ITY ID B TANK ID N mI I I 17 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE A WITH AREA CODE H EUfz O� PERMIT MUYSER PERMIT APPROVAL DATE PERMIT EXPRATION DATE CHECKS PERYITAMOUNT SURCHARGE AMT. FEE COVE RECEIPT# BY: _ EQRMe(6-29-66) THIS FORM MUST SEACCOYP AFACEmMEAFMrrATIOK FORM'A',w:W FOw'A' HASBEENFILED 1 DAT CESSING COPY 2 LOCAL AGENCY FILE COPY