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STATE OF CALIFORR WATER RESOURCES CONTI BOARD0 FUNDERGROUND STORAGE TANK PROGRAM T TANK PERMIT APPLICATION INFORMATION 2 PLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ r IVpdBI�EE�I��Bt1MAI-ENTADIHpI�EF*LpTRHT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK TL7'{IRUSEPL-WCESRIMPERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVEDACILITY/SITE NAME WHERE TANK IS INSTALLED:YLtJ HALT G S6 SHEL.L_ FARM TANK-YES❑ NO -+ •Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDA 7S2 4- - 4- 53 B. MANUFACTURED BY: C. YEAR INSTALLED 19 S D. TANK CAPACITY IN GALLONS: AjSO II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT W4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS lz 5 HAZARDOUS ❑60 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 8 C.A.S.A WA5TE OIL- CA.S.A: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,8 D A TYPE OF 1DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN SYSTEM F 2 SINGLE WALLED ❑4 SECONDARYOONTAINMENT ❑99 OTHER ❑ 1 STEBUIRON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM ❑B 1DD%METHANOL COMPATIBLE FRP MATE ❑ 9 8RDNZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER I�1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C.ORERIORJ��1 LINING 5 GUSSUNING i6 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP 2TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1SUCTION A U 2 PRESSURE A(U)3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION An 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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 C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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. P S 1 VISUAL CHECK PG)2 INVENTORY RECONCILIATION P 8 3 VADOSE WELL 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]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 S SI TORE) DATE LOCAL AGENCY USE ONLY COUNTY A JURISDICTION A AGENCY A FACILITY ID A TANK ID 4 CURB T LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE N WITH AREA COD! PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKS PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT0 BY: FORM B(6-2988) THIS FORM MUST BE ACCOMPANIEV uY A FACIUTY/SRE APPLICATION, FORM'A',UNLESS A =RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY