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STATE OFCALIFORNI ,,. WATER RESOURCES CONTRk ,aOARD FORM 'S' J -UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ,.,. .,� •.`COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. z 10 MApK ONLY L. , ❑ I NEWP011AR' ❑O flENEWAL PEAMIT. 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM I (:';❑2 INTENM PERMIT ❑1 AMENDED PERMIT- ❑6 TEMPORARY TANK CLOSURE ❑STANK REMOVED W . FACILITY/SITE NAME WHERE TANK IB INSTALLED: L QS C� FARM TANK-YES " NO Eff )V I TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY / I A OWNERS TANK IDE Lj B. MANUFACTURED BY: u 117, C.YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: Q p /) 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A• ❑ 1 MOTOR VEHICLE FUEL ❑ 2 P OLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑O DIESEL ❑S CHEMICAL PRODUCT 1 OIL �ppOp ❑/ GASAHOL ❑ 5 JET f UEL ❑ 6 AVIATION GAS .. ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL f 99 OTHER(DESCRIBE IN REM D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF F� ,1 HAZARDOUS SUBSTANCE STORED 8 C.A.S.t 1 v I 670 IL O I CAS.S: Ill. TANK CONSTRUCTION MARKONEITEMONLYINBOXA.B,C.AD A.TYPE OF'. . ❑I,MUSUE WALLED 7 SINGLE WALLED MTH EKTEAWR UNER ❑95 uNERowN SYSTEM �.' ❑ 2 SINGLE WALLED 4 SECONDARYCONTNRMENT ❑99 OTHER I STEEUADN ❑ 2 STAINLESS MR ❑9 FIBERGLASS 1 SPED.CIAO WIRBERGLSS REINFORCED PIATIC B.TANK ..:, ❑ 5 WNwm ❑ 6 POLYMNYLGlrDROE ❑ IALUMWUM ❑ 118614METRARGLCOMPATIBLEFRP MATERIAE,,!.: ❑ • :.:; . ❑.9 BRONZE ❑ 10 GALVANIZED VANIZED ❑ 95 LWKNOWN 99 OTHER C.INTERIOR• .0 I RUBBERLNED .. ❑2A MLWINO ❑ 9 EPDXY LINING ❑K PHENOUCUNNG LINING, `,;❑5,GLASS LINING ❑6 USJNED 95 IS9DIOWN -, ISUNWOMATUMCOWATIBLEWITHIW%METMI40L7 ❑YES 0N 99 OTHER FI) CORTREOCSTION . ❑ I:POLYETHU EWRAP . 2 TAR ORASPHMT 2 VOMwRAP 1 FIBERGLSS REWFOCED PLASTIC OION:.❑ 5 GTHODC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IFABOVE GROUND, U IF UNDERGROUND.BOTH IFAPPLICABLE A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 9 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A u l SINGLE WALLED A U 2 DOUBLE WALLED A U 5 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEELUA U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FOP A U B IOOWMETHAHOLCOMPATIBLEFRP 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 t l VISUAL CHECK P S 2 INVENTORY RECONCILIATION P t 0 VADOSE WELLS P t 4 ELECTRONIC MONITOR P t s GROUND WATER MONITORING WELLS P t t PRECISION TESTING P t i PRESSURETESTING P t 91 NONE P t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MONA) 2. ESTIMATED OUANTITY OF 1 WAS TANK FILLED WITH • SUBSTANCE REMAINING W GALLONS W ERT MATERIAL? E]YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S ' JURISDICTION! AGENCY S FACILITY ID! TANK IO S L CURRENT LOCAL AGENCY ACILITY ID 1 / APPROVED BY NAM! PHONE 1 WITH MEA COOK PERMITHUYSEA PERMIT EXPIRATION DATE ►EflYRAP►ROYK DAT! y CHECK# PERMITAMOUNT BURCHAROE ANT. FEE CODE ECEIPTa ti \•�, FORMSIF2B•M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION. FORM W.UNLESS A CHRDFNT F09u-.•