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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK /ANK PERMIT APPLICATION INFORMATION % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑G RENEWAL PERMIT D4ANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ I AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Zfo9 FACILITY/BITE NAME WHERE TANK IS INSTALLED: N / FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK 101 B. MANUFACTURED BY: /L C.YEAR INSTALLED [,/�� D. TANK CAPACITY IN GALLONS: 7 C o z) II. TANK C,DNfENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. A. ffl MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ I UNLEADED ❑2 LEADED DIESEL ❑G CHEMICAL PRODUCT ❑1 00. 8. 1 PRODUCT 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CA.S,I C.A.S.1: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A TYPE OF ❑t qPUNUEWALLED ❑0 SINGLE WALLED WITH WERIOH LINEA ❑95 wxWN SYSTEM ❑I SECONDARY CONTAINMENT ❑99 OTHER STEEUIDN ❑2 STAINLESS STEEL ❑7 FISERCAASS ❑ 1 STEEL DAD WYFIBEWVM REWORDED PLASTIC B.TANK 5 CONCTM ❑I POLYVRM CHLOFWE ❑ i ALUMINUM 1100%MMMOLCOMPATIBLEFRP MATERIAL ❑9 BIDN2E ❑ 10 GAIVAMZEO STEEL [3.95 U1IVDYM ❑ 99 OTHER C.INTERIOR ❑ 1%BBERLm ❑2 ❑S EPDXYUNRIG ❑ 1 PIENOUCUNING LINING ❑ 5 GIASSLBANG tmNED ❑%MN" ❑BUNNGL.UTERULCOWATINEMTH100%UMWIDL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ t POLYMA.MWIMP ❑2 TAR T ❑ 7 VINYL WIMP ❑/FIBERGLASS REWORDED PLASTIC PROTECTION ❑5 CATHOMPROTECTION 1 NDNE ❑%UWNOWN ❑ 92 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U J GRAVITY A U 91 NONE A U 9 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 7 LINED TRENCH A U 91 NONE A I.Q95 UNKNOWN U 99 OTHER A STEEL/RI A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC) A U 4 FISERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELCLAD W/FRP A U 8 II METHANOL COMPATIBLE FRP A U 9 OALVANIZED 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 t ( VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P t 3VADOSE WELLS P t 1 ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS P t. 8 PRECISION TESTING P t ? PRESSURE TESTING t 91 N ►S 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING IN _ GALLONS INERT MATERIAL? YES NO THFS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION I AGENCY/ IFACILITY ID I TANK ID/ CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE F WITH AREA CODE �7o U PERMITHUMBER PERWTAP"OVAL DATE PERMIT EXPIRATION DATE CHECK( PfgyITAMOUNT ti'ITWR'HABOE AMT. FEE CODE