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MA rE OF CALIFORN <br /> FORM /g,. <br /> WATER RESOUR <br /> TANK UND�OROUND cEs SON <br /> TANK P STORAGE T TR OARD <br /> COMPLETEASEPARATEFpRMWAPPLICATIONIM�TANK <br /> MARK ONLY t NEW PEavT TH THE FOLLOW WING IN FORMATIO <br /> ONE ITEM DRMATION FOR <br /> ❑2 INTERN x �S RENEWAL PERMIT R EqC <br /> PERMIT ❑<AMENDED PERMIT ❑5 CHANGE OF INFORMATION TANK <br /> FACILITY/SITE NAME WHERE TANK IS W43 ALLEp (�I G <br /> ❑6 TEMPORARY TANKC LrJ 7 PERMANENTLY CLOSED TANK <br /> I. TANK DESCRIPTION COMPLAEALL " osuRE �YKYy 10 <br /> ITEYS- <br /> IF UNKNOWN_ TANK REMOVED <br /> A. OWNERS TAI,K ID a SO SPECIFY FARM TANK-YES <br /> ❑ NO C V <br /> C. YEAR INS'A,1ED B. MANUFACTURED BY IV <br /> II. TANK CONTENTSM D TANK w <br /> IF(A 1)IS MARtFD,COPLE7E IT <br /> CAPACIry1N GALLONS: 0) <br /> A, ❑ - MO-OR VEHICLE FUEL ❑ 2 hTROLA/ EM C.IF(AtTA IS NOT MgRKED,CO w <br /> ❑3 CHEMICAL PRODUCT ❑t OIL B. C MPLETE ITEM D. <br /> ❑ 1 PRODUCT 0 1 UNLEADED ❑2 LEADED <br /> ❑S HAZARDOUS ❑ S_EM PT�r ONKNOWN 4 GASgHOL ❑3 DIESEL <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAOF ❑2 WASTE 7 METHANOL ❑5 JET FUEL ❑6 AVIATION N GAS <br /> HAZARDOUS SUBSTANCE STORED 8 C.A. ❑99 OTHER(DESCRIBE IN ITEM IA <br /> III. TANK CONSTRUCTION MARE ITEMONLYINSOXA,8 BELOW) <br /> C. <br /> a <br /> A. TYPE OF ❑ I DOUBLE WALLED 'S 94GLE WALLED WITH STERIOR UNI <br /> SYSTEM ❑2 SINGLE WALLED /SECONDARY CONTAINMENT ❑95 UNKNOWN <br /> ❑ I STEEL/IRON 2 STAINLESSSTEEL ❑99 OTHER <br /> B.TANK ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑3 FIBERGIASS <br /> MATERIAL -19 <br /> ❑4 STEEL CLAP W/FIBEgGLASS REINFORCED FUSTIC <br /> ❑9 BRONZE -I� IO GALVANIZED STEEL ❑95 UNKNOWN ❑B 100%METHANOLCOMPATIBLE FRp <br /> ❑ 1 RUBBER LINED J 2A yp LINING ❑99 OTHER <br /> C. INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑3 Epoxy LINING a PHENOLI <br /> LINING ❑ C LINING <br /> ❑ IS LINING MATERIAL'WITH 109%METHANOL' ❑ ❑95 UNKNO <br /> YES WN <br /> �1 ❑NO ❑ <br /> D. CORROSION F--] i POLYEiHLENE W' 2 TAR OR ASPHALT 99 OTHER <br /> PROTECTION ❑ 5 CATHODIC PROD 91 NONE 3VINYL WRAP ❑4 FIBERGUSS REINFORCEp pUSTIC <br /> 95 UNKNOWN <br /> IV. PIPING INFORMATION ( IFABOVEGROUND, ❑99 OTHER <br /> U IF UNDERGROU <br /> A. SYSTEM TYPE A U I SU A U 2 PRE ROUND A U ND,BOTH IF APPLICABLE <br /> B.CONSTRUCTION A U I Sln A U 2 DOUBLE WgLlEO 3 GRAVITY A <br /> C. MATERIAL A U 5 S7 A U 6 STAINLESS STEEL A U 3 PINED TRENCH A U 911 NONE A NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 9 . L A U 95 CONCRETE KNOWN A U 7 STEEL <br /> POLYVINYL <br /> W�RPIDE(pVC) A U 4 FIBERGLAS 95 NKNOWN A U 99 OTHER <br /> A U 99 OTHER A U 8 '00%METHANOL <br /> A U 91 NONE <br /> V. LEAK DETECTION SyLLE P FOR PRIMARY OR S FOR SECONDARY OL COMPATIBLE FRP <br /> P 5 1 VISUAL CHECK P $'ECONCIUATION q PRIM <br /> P 5 6 PRECISION TESTING P 'ESTING <br /> P s 91 NODOSE WELLS a S 4 ELEcrgOrylp MOElATO DETECTION SYSTEM MUST BE CIRCLED. <br /> VI. INFORMATION ON -�ANENTLy S 95 UNKNOWN R P S 5 GPOUND WATER MONITORING WELLS <br /> CLOSED IN PLACE P S 99 OTHER- <br /> 1. ESTIMATED DATE LAST USEC 2. ESTIMATED OUAry7II OF <br /> SUBSTANCE REMAIN IN <br /> UNDER 3. WAS TANK FILLED <br /> THIS FORM HAS BEE PENALTY OF PERJURY, GALLONS INFRTMA7ERIgL,WITH <br /> A'PICANTSN a7ugE) AND TO THE BE ST OF MY KNOWLED ❑YES ❑No <br /> OE,IS TRCIEgIyp CORRECT <br /> OW <br /> LOCALAGENCY <br /> COUNTY M IIaulGEN <br /> FACILITY ID p <br /> 1 ^ TANK IDA <br /> CURRENT LOCAL A/GENC (/,1 <br /> L.i. -6L—(l APPROVEDBVNAME <br /> PERMIT NUMBER PERMIT APPROVAL DATE PEgPNON E k WITH AREA CODE <br /> CHECK M M1T EXPIR <br /> SURCHARGE AMT. ATION DATE /� <br /> FEE CODE T,i <br /> RECEIPra <br /> AFACILITY/SITE Bn <br /> FORM a(6-29-ee) TNI$f I APPLICATION, FOR , <br /> y DATA PROCESSING COpy4''UNLESS RRENT FORM'A' <br /> HAS BEEN FILED <br />