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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM i+ (�/'//� TANK PERMIT APPLICATION INFORMATION �" "' TAN K — CpypLETE A SEPARATE FOgM WITH THE FOLLOWING ORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑S RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED OC/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,��-� �, S• �e<1111 777 FARM TANK-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK 101 B. MANUFACTURED BY: ((L C.YEAR INSTALLED c D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTORVEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑ 7 DIESEL ❑S CHEMICAL PRODUCT ❑A OIL (PRODUCT ❑ A GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL E] 99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.B - CA.S.E: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B.C.A D A TYPE OF ❑ I'DoumWANED O SINGLE WALLED WITH EXTERIOR UNFA E]95 MMIDWN SYSTEM 2 S143LEWAILED ❑ 1 SECONDARY CONTAMWNT ❑ 99 OTHER 1 STEEI6DN ❑2 STMNLESSSIEEL ❑7 FIBERGLASS ❑1 STEEL CUD W/FBEIIGm REINFORCED PLASTIC B.TANK ❑5 WNCAETE ❑9 POLYVNTLCILORDE ❑ 7 ALUURUM ❑ S 900%METIWIOLCOMPAT18(EFRP MATERIAL ❑9 BRONZE ❑ IO GALVANIZED STEEL ❑ %UNKNOWN ❑ 99 OIHFA ❑ I RJBBFA LINED 2 LINING ❑O EPDXY UNING ❑ 1 MENOLICUNINO C.INTERIOR LINING ❑ 5 WMLNM L4,r6 LHJNED ❑ %UNKNOWN ❑IS UNING UATUM COMPATIBLE WITH I OO■METKV40L? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHLINE WRAP ❑2 TARORASPHALT a 9K WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑91 NONE D119's UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U G GRAVITY A U 91 NONE --k-U 9 UNKNOW A U 99 OTHER S.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U O LINED TRENCH A U 91 NONE A U SC UNKN6WND A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESSSTEEL A U 9 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U ■CONCRETE A U 7 STEELCLAD W/FRP A U 6 I9 METHANOLCOMPATIBLE FRP A U 9 GALVANIZED STEEL A U NKN 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 1 VISUAL CHECK P A 2 INVENTORY RECONCILIATION ► ! 9 YADGSE WELLS P ■ A ELEC RO C MONIIOfl ► ■ S GROUND WATER MONITORING WELLS P ■. 6 PREGSIONTESTING P B 7 PRESSURE TESTING el NON P ■ B P ■ 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTRY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY F JURISDICTION E AGENCY B FACILITY ID B TANK ID B CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE 1 WIT"AREA CODE PERMIT NUYBlR PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PER MIT AMOUNT SURCHARGE AMT. fEE COD[ v RECEIPT/ BY: �,I,L / .<......,.um THIO MBY YIIRTB■AOCDYDLYIfp AY ACIPII TIIuic led lPmnu Cr%DLA •A-