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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 INF MATION FOR EACH TANK. MARK ONLY ❑ 1 NEWPERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENfLY CLOSED TANK ONE ITEM ❑2INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: :�J F A-) G rQ n f FARM TANK•YES❑ NO (V 1. TANK DESCRIPTION COMPLETE ALLITEMS•IFUNKNOWN—SOSPECIFY J� Fi A. OWNERS TANK ID p 3 B. MANUFACTURED BY: Gt cn C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OD D II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑<GASAHOL ❑5 JET FUEL ❑6 AVIATION GAG ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C.A.S.4 CA.S.M: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A TYPE OF ❑ I LEWAUED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 BNG D ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON E]2 STAINLESS STEEL [:] 3 FIBERGLASS ❑4 SIM CIADW/FIBERGLASS REINFORCED PLASTIC B. TANK MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE F-17 ALUMINUM ❑B 10091 METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑I RUBBER LINED ❑2 INING ❑3 EPDXY UNING ❑ 4 PHENOLIC UNING LINING E]5 GLASS LINING UNLINED E]95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLE WITH 10U1METHANOL7 ❑YES F-1No ❑99 OTHER D. CORROSION ❑ I POLYETHLEI4EWRAP ❑2 TARORASPHALT ❑3 P ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICAE A SYSTEM TYPE A U 1 SACT A U 2 PRESSURE A U 3 GRAVITY L 9 NE U 95 UNKN A U 99 OTHER B. CONSTRUCTION A A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 91 NO E A U 95 UNKNOWN A U 99 OTHER A 1 STE 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 810D%METHANOLCOMPATIBLEFRP A U 9 GALVANIZED 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VAO WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OFGALLONS S WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E]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 p JURISDICTION p AGENCY• FACILITY ID N TANK ID# 3 ` = = I oG //-FPT)- U tS 0 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEI ' by. S�p FOflMB(6-29-SB) THIS FORK MUST BE ACCOMPANIED BYA-.wCILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASSEENFILIED DATA PROCESSING COPY--