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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORM .00 ro.Lo AYION FbR EACH tANk. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMD 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑B TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 12.CL JE, (W)eP/ FARM TANK-YESED] NO N 1. TANK DESCRIPTION COMPLETE ALL ITEMS AP UNKNOWN–BO SPECIFY J A. OWNERS TANK ID Nw B. MANUFACTURED BY: ✓f,LZ. � C. YEAR INSTALLED 14 7-1 10. TANK CAPACITY IN GALLONS: -3 po41 11. TANK CONTENTS IF(AA),IS MARKED,COMPLETE ITEM Q IF(A.1),14 NOT MARKED,COMPLETE ITEM D. A. Eall MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑'DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET NEL ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑ ❑8 AVIATION GAS ❑ ❑2 WASTE ❑1 METHANOL ❑99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ItEM ONLY IN BOK A,B,C,a D A. TYPE OF WAS ❑3 SINGLE WAULEDWITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SRIGLEWALIED ❑4 SECONDARYCONTAINMENT ❑99 OTHER Ea I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL RETE 5 CONC ❑B POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP ❑9 BIONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RIIBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑A UN=LINING LINING F-15 GLAMUNING [-]N UNLINED KNOWN ❑B LNANG MATERAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETI%ENE WRAP ❑2 TAR ORASPHALT E341ANYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICpROTECRGN ❑91 NONEIn 95 UN(NOWT! ❑99 OTHER _ IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U "OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE Agfogfi UNKNOWN -7--u 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T BTEELCLAOW/FRP A U 8 10D%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR B FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK V 9 2 INVENTORY RECONCILIATION P 6 3 VAOOSE WELLS P 6 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS 8 PRECISION TESTING 0 6 7 PRESSURE TESTING P 6 91 NONE P 6 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLON6 INERT MATERIAL? ❑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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID R 3 � Ioo ( 1l 3 o 1 a 1 CURRENT LLO.CALL AGENCY FACILMYY 10 A APMOV[D BY NAME PHONE N VRIMH AR[A COD! PERMITUMMBER 2 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. F!!COD[ RECEIPT A BY: FORM B(8-2989) THIS FORM MUST BE ACCOMPA.. ,Y A FACILITY/SITE APPLICATION, FORM 'A',UNLES—JRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY