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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': Ll--- UNDERGROUND STORAGE TANK PROGRAM (azTANK Ll/ TANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK 18 INSTALLED: -21q1 W (/ rC. �/'IC�Pi�S��-- FARM TANK-YES NO W 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ON l _ �/ B. MANUFACTURED BY: 1w(cam N C. YEAR INSTALLED (L D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED a2 LEADED ❑3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑ 4 OIL I 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 8 CAS.N CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.A D A TYPE OF ❑ I DptJ6LE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM FiX swUE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER FVf I STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CIADW/RBERGLASS REINFORCED PLASTIC L TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81M%METHANOL COMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 FtIENBOt LINING LINING ❑ 5 GLASS LINING ❑6 UNUNED E245 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1084 METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VIWtWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE r9loruNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTIO A U 2 PRESSURE A U 3 GRAVITY A U 9/ NONE A 95 UNKNOW A U 99 OTHER B. CONSTRUCTION A U A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U EEL/1 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 B CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 IVIS _ P R N P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTLIjG P 8 7 PRESSURE TESTING P S 9/ NONE P S 95 UNKNOWN P B 99 OTHER_ VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k III=JURISDICTION M II AGENCY k FACILITY ID M T`A'NK ID t O O l v( o c CURRENT LOCAL AGENCY FACILITY ID t APPROVED BY NAY[ PHONE t WITH AREA CODE fC '- k PERMITNUMBER PERYITAPPROVALOATE�PoRMIT EXPIRATION DATE CNECK t PERMIT AMOUNT SURCHARGE MT. RECEIPT t BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY