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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFO TION FOR EACH TANK. Qp MARK ONLY ❑ I NEW PERMIT ❑ 0 RENEWAL PERMIT CHANGE OF INFORMATION ❑ I PERMANENTLY CLOSED TANK ONE ITEM ❑ 2INTERIM PERMIT ❑ / AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED c9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0--jFARM TANK•YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-80 SPECIFY A OWNERS TANK IO t C S. MANUFACTURED BY: ueQ( - - 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 P OLEUM ELI C, ❑ 1 UNLEADED ❑ 2 LEADED ❑ 7 DIESEL ❑0 CHEMICAL PRODUCT LZ4 00. - [:] 1 T ❑1 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS C] 80 EMPTY [:]95 UNKNOWN WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CA.S.1 C.A.S.1: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑ IDIAILED F-10 SINGLE WALLED WITH EXTERIOR LNEA ❑%"'Nom SYSTEM SNGLE WIUFD ❑1 SEMMRf CONTAOMNT ❑ 99 OTHER STEEURON ❑2 STMNESSSTEEL ❑S RBEROIASS ❑ 1 SIM CUD WIRBERGIASS FEMORCED PLASTIC 8.TANK ❑S CONCRETE ❑6 POLYVINYLOLOROE ❑ 7 ALUMMM ❑6 10011 MERIANOL COMPATI&E FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ %UNKNOWN ❑%OTHER G INTERIOR ❑ I AUBBERLM El2 INC ❑]EPDXY LINING /PHENOLIC AMNO LINING ❑5 GL IM NNG 6 0A1NM ❑95 mxWN ❑ SLUNG MATERIAL COMPATIBLE WHIN IW%METHANOL? ❑YES ❑ NO ❑99 GTHER D.CORROSION ❑ I POLYET UNEWRAP ❑2 TAO OR T ❑ 9 VINYL WRAP ❑1 neeRGlASSREIMORCEDPUSTIC PROTECTION ❑5 CATHOMPROTECTION [—]95 um OWN ❑ 99 OTH M IV. PIPING INFORMATION CIRCLE A IFABOVEGROUNO, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A 0 C A U 91 NONE A u 95 UNKNOWN A U 99 OTHER 8.CONSTRUCTION AI SINGLE A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A L C.MATERIAL A U 5 ALUMINUM A U G CONCRETE A U I STEELCLADW/FRP A U B IW'q 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 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P t l VISUAL CHECK F 6 2 INVENTORY RECONCILIATION P 9 S VADOSE WELLS P t 1 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P t. t PRECISION TESTING P t 7 PRESSURE TESTING 1 91 NONE P t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATELAST�lc USED(MO/YR) 2.ESTIMATED OUANTIIY OF S.WAS TA NK FILLED WITH SUBSTANCE REMAINING IN � INERT MATERIAL? ❑YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNAL URE) DATE LOCAL AGENCY USE ONLY COUNTY 1 JURISDICTION 6 AGENCY/ FACILITY ID 6 TANK ID 1 0 1 U -) / U c) 1 o E] CURRENT LOCK AGENCY FACILITY ID I APPROVED BY NAY! PHONE I WITH AREA COD! PERMIT NUMBER PERMIT APPROVAL DAT! PERMIT EXPIRATION DATE CH / PLpYIT ECKAMOUNT AAgOE AMT. FEECODE T1Eo..PT BY: n /�/