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STATE OF CALIFORN�te WATER RESOURCES CONTRIMARD FORM 46': UNDERGROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: , U)01 FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY 3C) A. OWNERS TANK IDR 0 B. MANUFACTURED BY: C. YEAR INSTALLED 161 0. TANK CAPACITY IN GALLONS: �4 coo 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. O A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. �1 UNLEADED ❑ 2 LEADED ❑3 DIESEL c F-1 3 CHEMICAL PRODUCT [-] 4 OIL �(PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.RC.A.S.R: ><III. TANK CONSTRUCTION MARK ONE EM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [j2/2 SINGLE WALLED ❑4 SECONDARYOONTAINMENT ❑99 OTHER [�er1 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ❑2 LKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOUC UNI NG LINING ❑5 GLASS LINING 6 UNLIN C. INTERIOR ED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH I00%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 IWLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-] 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A(UY2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION ANY, SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U i STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER '� LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. '�7 I P 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS {'..�✓JI P S 6 PRECISION TESTIN S ] PRESSURETESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE UIIUJJJJ... 1. ESTIMATE D T LAST USED(MO/VR) 2. ESTIMATED U OF 3.WAST FFD WITH SUBSTANC R AI G IN IN T L? ❑YES [:] NO GALLONS THIS FORM WS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION R AGENCY R FACILITY ID R TANK ID# 3 jI ol D I I I L D U O l CURRENT LOCAL AGENCY FACILITY IDM APPROVED BY N411E PHONE#WITH AREA CODE wtwl3 �S ` I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERT AMOUNT SURCHARGE AMT. FEE CODE RECEIP MIT# BY: Ah W FORM B(34-88) THIS FORM MUST BE ACCOMPANIED ur FACILITY/SITE APPLICATION, FORM`A',UNLESS A CU . T FORMA' HAS BEEN FILED DATA PROCESSING COPY