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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM ' TANK [/// TANK PERMIT APPLICATION INFORMATION `y`= COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 ORMATION FOR EACM TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSEDT ONE ITEM (D2 INTERIM PERMIT ❑A AMENDED PERMIT E]6 TEMPORARY TANK CLOSURE ®8 TANK REMOVED FACIUTY/SITE NAME WHERE TANK 18 INSTALLED: Port of Stockton Food Dist . FRAY TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 2001 E . Fremont A. OWNERS TANK IDN B. MANUFACTURED BY: Unknown C. YEAR INSTALLED U n k o w n ID. TANK CAPACITY IN GALLONS: 1000 II. TANK CONTENTS IF(A.1),1S MARKED,COMPLETE ITEM C.IF(A1),11 NOT MARKED,COMPLETE ITEM D. A. ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. G 1 UNLEADED ❑2 LEADED ®3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ®I PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY F]95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER IDESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C A.S.N C A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.S,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SMILE WALLED WITH EXTERNO(LINER ❑%UNKNOWN SYSTEM 2 SINGLE WALED ❑A SECONDARY CONTAINMENT ❑M OTHER ® 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CUD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑1100%METHNOL COMPATIBLE FRP MATERIA) ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBERUNED ❑2 AL3(YD LINING ❑3 EPDXYUNING ❑/PHENOLCUNING LINING ❑5 GLASS LINING .❑6 LMUNED ❑95 mm" ❑ IS LINING MATERIAL COMPATIBLE WITH)BTI%MEDNNOL7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ i POLMNENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WMA ❑1 FIBERGLASS FIEWO tt;EID PLASM PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE • U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTIONA 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN • U %OTHER SSTEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 619011METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U %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. S I VISUAL CHECK ©6 2 INVENTORY RECONCILIATION P F 3VADOSE WELLS P E A ELECTRONIC MONITOR P E 5 GROUND WATER MONITORING WELLS PRECISION TESTING P E 7 PRESSURE TESTING P S 91 NONE P E 95 UNKNOWN P E MOTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2 ESTIMATED QUANTITY OFOALLONE 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL) E]YES E]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AV TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE Randy Thomas LOCAL AGENCY USE ONLY COUNTY N JURISDICTION F AGENCY* FACILITY ID F TANK ID E 511 CURRENT LOCLL•OlNCY F•CIM1Y 10I vv MIIAOKD EY NAY[ RWN[/MRM MG O[CO PERMIT MUMMA KRYR AIMMAL DAT[ MFIAT nNUTION DAT[ /D�Z4`--f v v CHECK• PERMIT AMOUNT SURCHARGE AWT. I[[ D[ RE COC[IPT N EY: 5- FORMB(6-29-M) Y MFORMMMMA000'—"—IBYAFACLMWMMBSUTWK FORM'A', Nv' '—VW P11111-9 IWBEENFEED,,E' N�\V 1 DAFA(1ROCESSING COPY 2 LOCAL AGENCY OM 3 1"COPY