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STATE OF CALIFOR4 WATER RESOURCES CONTF*BOARD <br />FORM'S': UNDERGROUND STORAGE TANK PROGRAM <br />TANK TANK PERMIT APPLICATION INFORMATION <br />COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK, <br />MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION <br />ONE ITEM 2 INTERIM PERMIT El 4 AMENDED PERMIT & TEMPORARY TANK CLOSUF <br />FACILITY/SITE NAME WHERE TANK IS INSTALLED:; C ? � �J / ,,� c G <br />I. TANK DESCRIPTION COMPLETE ALL ITEMS -IF UNKNOWN -SO SPECIFY <br />A OWNERS TANK ID # B. MANUFACTURED BY: <br />C. YEAR INSTALLED <br />`7 I D. TANK CAPACITY IN GALLONS: <br />7 PERMANENTLY CLOS <br />® 8 TANK REMOVED 115 <br />S <br />12_ FARM TANK - YES ❑ NO <br />IL TANK CONTENTS IF (A.1), IS MARKED, COMPLETE ITEM C. IF (A.1), IS NOT MARKED, COMPLETE ITEM D. <br />A. n 1 MOTOR VEHICLE FUEL 0 2 PETROLEUM B, C W 1 UNLEADED 2 LEADED 3 DIESEL <br />3 CHEMICAL PRODUCT F-] 4 OIL 1 PRODUCT E14 GASAHOL 5 JET FUEL E AVIATION GAS <br />5 HAZARDOUS Is80 EMPTY F-1 95 UNKNOWN 2 WASTE El 7 METHANOL 99 OTHER (DESCRIBE IN ITEM D, BELOW) <br />D. IF NOT MOTOR VEHICLE FUEL, ENTER NAME OF <br />HAZARDOUS SUBSTANCE STORED & C.A.S. 4 C.A.S. #: <br />I{ r A Alv f %kileTL11 ll TinN UAQr nNF ITFM nNLV IN BOX A. B. C. & D <br />IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND, BOTH IF APPLICABLE <br />A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br />B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE C;lN U 95 UNKNOWN A U 99 OTHER <br />A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br />C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 6 1 oa% METHANOL COMPATIBLE FRP <br />A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br />V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, OR S FOR SECONDARY, A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br />P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br />P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE S 95 UNKNOWN P S 99 OTHER <br />VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br />i. ESTIMATED D} TE LAST USED (MO/YR) f 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br />11rk <br />�.1 SUBSTANCE REMAINING IN INERT MATERIAL? YES g NO <br />GALLONS <br />THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLiCANI:�NA7(PRIM D&SIG ATlURE)-------DATE .yX� <br />I t .',> v.:• 11 � \� lir L? af�1 "-7. <br />11,27 <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # <br />CURRENT LOCAL r FACILYTYI - <br />PERMIT NUMBEERR i�Y�T/ <br />AGENCY # <br />FACILITY ID # <br />Q2:Lgf3� <br />APPROVE BY NA E .!}��J' <br />.0 R — <br />PERMIT APPROVAL DATE <br />I I PE MIT EXPIRATION DATE <br />CHECK N PERMIT AMOUNT I SURCHARGE AMT. I FEE CODE I RECEIPT* <br />FORM B (6-29-68) THIS FORM MUST BE <br />A FACILITYISITE APPLICATION, FORM 'A', UNLESS A <br />DATA PROCESSING COPY <br />TANK ID# <br />Lo I <br />PHONE # WITH AREA CODE <br />BY: <br />FORMA' HAS BEEN FILED <br />