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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. N z <br /> MARK ONLY ❑ 1 NEW PERMIT Ej 3 RENEWALPERMIT E] 5 CHANGE OF INFORMATION 13 PERMANENTLY CLOSED TANK 10 <br /> ONE ITEM 02 INTERIM PERMIT ❑1 AMENDED PERMIT 0 6 TEMPORARY TANK CLOSURE TANK REMOVED <br /> C)29111 GL7 <br /> FACILITY/SITE NAME WHERE TANK 18 INSTALLED: �r FARM TANK-YES 0 NO W <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY �ZD <br /> A. OWNERS TANK IDR B. MANUFACTURED BY: (,V <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: QO <br /> IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑1 UNLEADED [:3 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 1 OIL PRODUCT ❑/GASAHOL 5 JET FUEL ❑6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY [-]95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.R: <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D <br /> A TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINEA ❑95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 1 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS /STEEL CLAD W/RBERGLAS6 REINFORCED PLASTIC <br /> B.TANK F-�5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 6 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR I RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 1 PHENOLIC LINING <br /> LINING ❑5 GLASS UNING 6 UNLINED 95 UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:]NO 99 OTHER <br /> D. CORROSION ❑ I POLYEMLENE WRAP ❑2TAR OR ASPHALT 3VINYL WRAP /FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION o 5 CATHODICPROTECTION 0 91 NDNE 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 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 U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/TAP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN 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 S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 / ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL7 YES [:]NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R I TJURISDICTION R AGENCY R FACILITY IID R TANK ID R <br /> \^` CURRENT LOCAL AGENCY FA1CILRY ID R APPROVED BY NAME PHONE E WITH AREA CODE <br /> .'� PEAIT <br /> MNUM1 " PERMIT APPROVAL DATE PERMIT EXPIRATION DATE p\\V <br /> CHECK F PERMIT AMOUNT SURCHARGE AMT. FEE CODE -C---Ts BY: <br /> FORM B(6-29-661 THIS FORM MUST BE ACCOMPANIED BY AMACILITY/SITE APPLICATION, FORM 'A'.UNLESS A CURRENT FORMA' NAS BEEN FILED <br />