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STATE OF CALIFORNIA ATER RESOURCES CONTROL BOARD FORM 16% UNDERGR NK PROGRAM az TANKTANK PER 1 INFORMATIONCOWL TF A SEPARATE F LL INFORMATION FOR EACH TANK. 10 MASK ONLY ❑ 1 NEW PERMIT f7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDDT ONE ITEM [:]2 INTERIM PERMIT []4 AMEND®PERMIT F-1 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED CA) FACNJTYANTE NAME 11MERE TANK NI UNITALL Q d F � FARM TANK-YE8❑ NO W OD 1. TANK DESCRIPTION comPLETE ALL RaMS-w uwAom—so smcwy A.OWNERS TANK IDN B. MANUFACTURED BY: cy) C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: aO O II. TANK CONTENTS W(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1).18 NOT MARKED,COMPLETE REM D. A 1 MOTOR VEIACLE FUEL F--j 2 PETROLEUM B. C. [-]1 UNLEADED [g)2 LEADED F 3 DIESEL 3 CHIEMICAL PRODUCT E]4 OIL KA 1 PRODUCT r--j 4 GASAHOL F-� 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS Ei 80 EMPTY o 95 UNKNOWN n2 WASTE 07 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.N C.A.S.If: 111. TANK CONSTRUCTION MARK ONE REM ONLY IN BOX A.B.C.a D A.TYPE OF ❑ i DOUBLE WAILED E]3 SINGLE WALL®WITH EXTERIOR UNER 95 UNKNOWN SYSTEM 2 swDLE WAUID El 4 MOON CONTAINMENT 99 OTHER ❑ I STEBJIRON 0 2 SUINNLESS STEEL 0 3 FNIERGIASS F-14 STEEL CUD WIRBE IMM REINFORCED RASTIC wT L TA5 OMDIETE � INYL 8 POLYVOtORYDE 7 ALUTAW �8 108%METHANOL COMPATIBLE FRRP �+►L ❑9 wam Ell 0 GALVANIZED MR K 95mm" 099 OTHER I Rl1BBER UNH) F1 2 ALKYD LNNG E]3 EPDXY LNNG F-1 4 PHINOUC UNONG UNNIG F-15 GLASS LANG [:]6 mm 91 96 LN(IIONM E]IS UNIIG MATEIVAL COMPATIBLE WITH IW%METHANOL? YES [:]NO 99 OTHER p,001 ❑ 1 POI.YETHLENE WRAP 2 TAO OR ASPHALT 3 VINYL WRAP 4 R18ERGLASS REINFORCED PLASTIC PROTECm [:]5 CATHDOICPROTECf10N 91 NONE 95 W0100 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A, Tm A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER L COWN)CTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER 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 Ci.uAlav t A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FFP A U 9 GALVANIZED STEEL AQ 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P f 1 VISUAL CHECK P i 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P i o ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P • 6 PRECISION TESTING P S 7 PRE35<RRE TESTING P i 91 NONE <ntM96 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OFOALLONST 3.WAS TANK FILLED WITH T SUBSTANCE REMAINING IN 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 N JURISDICTION N AGENCY N FACILITY ID N TANK ID N 3 9 0 0 / ly / 1 10 la 10 2- CUMWW&qCAL AGENCY FACILRY w f APPROVED WY NAME PHONE 0 WRN AREA CODs 1 CM2 ! Pamw NUYBEII PERIN I APPINMAL DATE PERMIT EXPIRATION DATE CHECK f PERMIT AMOUNT iUIICNAROE AYT. MCC" IECEIPT/ BY: FORM B 0-n," tIMflft MINT . W A fACR,ITYi=APPLICATION, FORMFqPW Alit M" . . .____. -- _ .-__ __ - - n^nv -