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b I A I t OF CALIFORNIA WATER RESOURCES CONTROL BOARD ~ <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION : 1 <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> ONE(MARK ONLYTEM 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION `•,' u'u 10 <br /> 2 INTERIM PERMIT E]4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE �6 TANKK REMOV DCLOSED TA <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: /� w <br /> CU ove /M7GAf FARM TANK-YES D N W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (40- Q <br /> A. OWNERS TANK ID p <br /> B. MANUFACTURED BY, -4(J K CO <br /> C. YEAR INSTALLED (� D. TANK CAPACITY IN GALLONS: <br /> .157-06 <br /> If. TANK NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,C ETE ITEMM D. D <br /> A I MOTOR VEHICLE FUEL M 2 PETROLEUM <br /> BC I UNLEADED 2 LEADED 3 DIESEL <br /> LON <br /> HEMICAL PRODUCT ❑4 OIL I PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> AZARDOUS ❑60EMPTY �95 UNKNOWN 2 WASTE 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> OTOR VEHICLE FUEL,ENTER NAME OFOUS SUBSTANCE STORED&C.A.S.N <br /> C A.S.p: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.&D <br /> [TANK <br /> ❑ 1 UUUBLLWAUED �3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN <br /> El 2 SINGLE WAILED 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> 1 STEEUIRaN ❑2 STAINLESS STEEL ❑3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> 5 CONCRETE E]6 POLYVINYL CHLORIDE 0 7 ALUMINUM B IOD%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL E]95 UNKNOWN 99OTHER <br /> ❑ I RUBBER LINE 2 ALKYD LINING❑5 DLASSLINING ❑3 EPUKY LINING d PHENOLIC LINING <br /> 6 UNLINB3g5 UNKNOWN <br /> IS LINING M4TFAIAL COMPATIBLE WRH 100%MLTHANOL7 ❑YES D NO ❑99 OTHER <br /> N'CORROSION ❑ 1 POLYETNFNE WflAP 2 TAO OR ASPHALT ❑3 VINYL WRAP 0 4 FIBERGLASS REINFORCED PLASTIC <br /> ❑5 CAIVODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE <br /> A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A I 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> C.MATERIAL <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CMLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> A U 5 ALUMINUM A U B CONCRETE <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 7 STEEL CLAD W/FRP A U 8 10096 METHANOL COMPATIBLE FRP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 8 1 VISUAL CHECK P • 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 6 7 PRESSURE TESTING <br /> P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE UST USED(MO/YR) <br /> 2. ESTIMATED OUANTITV OF <br /> SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH <br /> GALLONS INERT MATERIALS DYES [:] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCYN <br /> FACILITY IDN � TANK ISM <br /> DGRRENT LOCAL AGENCY FACILm IDI <br /> ^ APPROVED BY NAME PHONE I WITH AREA CODE <br /> PERMIT NUMBER C 0 / 7 <br /> PERMIT APPROVAL DATE PERMIT EXPIRATION DAT! r6�p <br /> CHECKN PERMITAMOUNT SURCHARGE AMT. <br /> FEE CODE RECEIPT• BY: <br /> FORM B(8-29-BBI THIS FORM MUST BE ACCOMPANIED a.-.FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CL <br /> 9ftNT FORY'A' HAS BEEN FILED s <br /> DATA PROCESSING COPY <br />