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STATE OF CALIFORNI/ WATER RESOURCES CONTROL ')ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COM ETE A SEPARATE FORM WITH THE FOLLOWINGINFORMATION FOR EACH TANK. MARKONLY NEW PERMIT ❑D RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOUD-19k__ ONE ITEM 1 14TERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED am t FACILITY/SITE NAME WHERE TANK IS INSTALLED: E FARM TANK-YES❑.. -51. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Gy 10 A. OWNERS TANK ID N 0 B. MANUFACTURED BY: e O YEAR INSTALLED s D. TANK CAPACITY IN GALLONS. ,7 0n 0 A 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. }-• A. I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED 0 DIESEL Q7 ❑ O CHEMICAL PRODUCT ❑4 OIL ®j ppppUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C 11A. CA.S.p: .III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,a D A TYPE OF ❑ I DOISIE WAl1ID ❑ 0 SINGLE WALLED WITH MEW LINER ❑95 UW40WN SYSTEM f 2 SINGLE WALLED ❑ 4 SECONDARYCOMAINMENf ❑99 OTHER jal"STEEUIRON ❑ 2 SIMNESSnR ❑3 RBarAAS$ ❑ 4 SMR CLAD W/FIBEAGIASS REINFORCED PLASTIC S.TANK ❑ 5 CONCAEfE F1 6 POLYWNYL CHLORDE ❑ 7 ALUMIMIM ❑ 8 100%MCHANOICOMPARBLEFRP MATERIAL � ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR I RMBERUNED F12 AMU" ❑ 7 EPDXY LW ❑ 4 PI104000 UWNG LINING ❑ 5 GLASS LINING j;J�UUN® ❑ 95lN(740WN ❑ ISUNNGMATERALCOMPATRIIEEMMTTH10D%MEDOML? ❑YES ❑NO 99 Ono D.CORROSION ❑ 1 POLMHLENE WRAP U 2 TNI ORASPRALT ❑ 7 WIYL WRAP ❑ 4 RBERGIASS REINFORCED PLASTIC PROTECTION ❑ 5 CATMODO RIOTECRON ❑91 NOIR ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U O GRAVITY A U 99 OTHER B. CONSTRUCTION A(Uj I SINGLE WALLED A U 2 DOUBLE WALLED A U O LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U O POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE G MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U %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 1 VISUAL CHECK P S 2 INVENTORYRECONCILIATION P S O VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS 1 P S B PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE USED(MO/YR) 2. ESTIMATED OUANTITY OF 7. WAS TANK LLD WITH SUBST R INING IN .0..0. INER RI ? ❑YES ❑ NO THIS F01WHk BEEN COMPLETED UNDER PENALTY OF AERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY p FACILITY ID N TANK ID# 60 3 ro p / CURRENT LOCAL AGENCY FACILITY 10• O E. PH NE N WITH DE PERMIT NUMBER PFR IT ALD/CT'E' PERMIT EXPIRATION D CHECK I PERMIT AMOUNT SURCHARGE A FEE CODE RECEIPT BY: / 1 J FOflM 813-IASL THIS FORM MUST BE ACCONPANIEs:./AFACBTTY15TfE MPUGTON, FORM 'A',UNLESS AZI+NRFJIT FORMA' HAS BEEN FILED