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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ='m COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: �.� E, F2Eh10 57r FARM TANK-YES❑ NOW 7 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 0 e A. OWNERS TANK ID N 0Nr-lQQtAJA1 B. MANUFACTURED BY: N oYJAI C.YEAR INSTALLED ` 0 KI/V I 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- 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL [jj1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C A.S.N C.A.S.M All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,l D A. TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ED<—SINGIE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER �EL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MR DEAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CINXTE ❑6 POLYWNYLCHLORIDE ❑7 ALUMINUM ❑810D%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR 1 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING E]4 PHENOUCUNING LINING ❑5 GLASS LINING EalrrNLINED ❑ 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ©1 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A SYSTEM TYPE AM, SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U41 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 10 METHANOLCOMPATIBLE FRP 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. 5 P S 1 VISUAL CHECK O 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIALS ❑YES E] 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 S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY# FACILITY ID N TANK ID# Em = = 10101"-dololc/ l CURRENT LOCAL AGENCY FACILITY ID M APPRp D BY NAME PH NEM WITH AREA CODE V 3 PERMIT NUMBER PERMIT APPROVAL DATE RMIT EXPThATIOND CHECK M PERMIT AMOUNT -SURCHARGE AMT. I FEE CODE BY: I FORM B(3-7-BR) THIS FORM MUST BE ACCOMPANIEu 6Y A FACILITY/SITE APPLICATION, FORM 'A',UNLE88 ENT FORMA' HAS BEEN FILED / ATA PROCESSING COPY