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STATE OF CALIFO FORM 413% wo WATER RESOURCES C UNDERGROUND STORAGE TANK OR RAM TANK COMPLETE BAN RPITHTHEFOLLOWINGINFOERMI WGRAM APPLICATION INFORMATION MARK ONLY ❑ 1 NEW PERMIT RMATION FOR EgCN TANK, ONE ITEM ❑3 RENEWAL PERMIT ❑2 INTERIM PERMIT ❑5 CHANGE OF INFORMATION s FACLLITrI NAME WHEgE TANK IS INSTALLED:❑4 AMENDED PERMIT ❑7 PERMANENTLY CLOSE ,o• 1 ❑6 TEMPORARY TANK CLOSURE NK I. TANK DESCRIPTION 0 TANK REMOVED COMPLETE ALL ITEMS-IF UNKNOWN— N FARM TANK-YES NO A. OWNERS TANK ID k SO SPECIFY C. YEAR INSTALLED Oc B. MANUFACTURED BY: « If. TANK CONTENTS 1-4 cc D. TA CAPACITY IN GALLONS: IF(A2 P IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MAgKE11,COMPLETE ITEM D. ov A. 1 MOTOR VEHICLE FUEL ❑ ❑3 CHEMICAL PRODUCT 2 PETROLEUM ❑4 OIL B. ❑5 HAZARDOUS C ❑ I UNLEADED ❑2 LEADED ❑80 EMPTY g5 UNKNOWN I PRODUCT ❑4 LEADED 3 DIESEL D. IF N07 MOTOR VEHICLE FUEL,ENTER NAME OF ❑2 WASTE 5 JET FUEL ❑ HAZARDOUS SUBSTANCE STORED A O.q.3 k ❑7 METHANOL 6 AVIATION GAS III. TANK CONSTRUCTION ❑99 OTHER(DESCRIBE IN ITEM D,BELOWI MARK ONE ITEM ONLY IN BOX A.B, C'A'S.#: A TYPE OF ❑ SLEWALLED C,8 D SYSTEM ❑3 SINGLE WALLED WITH EXTERIOR LINER 2 NGLE WgLLEp ❑4 SECONDARY CONTAINMENT ❑95 UNKNOWN B. TANK 1 STEELMON ❑2 STAINLESSBIEEL ❑99 OTHER MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE 3 FIBERGLASS ❑q STEELCLAOW/FIBERGUSS REINFORCED PLASTIC ❑9 BRONZE ❑IO GALVANIZEDSTEEL /ALUMINUM ❑8""I METHANOL COMPATIBLE FRP ❑1 RUBBER UNED P6�I UNKNOWN ❑99 OTHER C.LINING INTERIOR ❑5 GLASS UNING ❑2 UNLINEDLKYD LINING 3 EPDXY LINING ❑6 UNLINED ❑ ENOLIC LINING ❑ISUNING MATSTIAL COMPATIBLE WITH 1096 MEfHANOL' ❑ 95 UNKNOWN YES ❑NO 98 OTHER D. CORROSION ❑1 PoLYETHIENEWRAP PROTECTION ❑ ❑2 TAR ORASRMI.T 3 L WRAP 5 CATHODIC PROTECTION 91 NONE ❑<FIBEgGUSS flEINPoflCED FUSTIC IV. PIPING INFORMATION CIRCLE A IFgBOVE GROUND 95 UNKNOWN ❑99 OTHER A. SYSTEM TYPE A 1 SUCTION U IF UNDERGROUND,BOTH IF APPLICABLE B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 PRESSURE A U 3 GRAVITY A U 2 DOUBLE VypLyEp A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U i STEEUIROry A U 3 LINED TRENCH A U 91 NO C. MATERIAL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PyC) A D A U 95 UNKNOWN A U 5 ALUMINUM A A U 99 OTHER A U 9 GALVANIZED STEEL q U 6 CONCRETE A U 7 STEEL CLAD W/FAP 4 FIBERGLASS PIPE A U 91 NONE 5 UNKNOWN A U 99 OTHER A U 8 10D96 METHANOL COMPATIBLE FRP v. LEAK DETECTION SYSTEM 1 M CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A p "P S 1 VISUAL CHECK $ 2 INVENTORY gECONCILIATION p BINARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 6 PRECISION TESTING 8 3 VADOSE WELLS P $ 4 ELECTRONIC NIC MONITOR p S ]PRESSURE TESTING P 8 91 NONE VI. INFORMATION ON TANK PERMANENTLY P E 95 UNKNOWN $ 5 GROUNDWATER MONITORING WELLS 1. ESTIMATED)DATE LAST USED(MO/YR) CLOSED IN PLACE P $ 9s orHER- 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN THIS FORMHAS BEEN 3. WAS TANK FILLED WITH COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,lS TRUEAND CORRECT. LONS INERT MATERIAL? APPLICANT'S NAME(PgINTED$SIGNATURE) ❑YES NO LOCAL AGENCY PATE USE ONLY COUNTY# JURISDAG� 3 �y !//J 11:AM 10 k qr1 N/ TANK ID B CURRENT LOCAL AGENCY FACILITY ID k v O/ � /� /'] / U/5 17/ APPROVED BY NAME (/ (�/ PERMITNUMBER /- PHONE III WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT SURCHARGE AMT. FEE CODE ECEIPT N FOR"(6-29-88)(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FOgM'A' HAS DATA PROCESSING COPY BEEN FILED