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STATE OF CALIFORN0 - WAT17R RESOURCES CONTR 30ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT AF PLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITF THE FOLLOWING INFORMATION FOR EACH TANK. - Z MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPE MIT ❑5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPE IMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 07 W FACILITY/SITE NAME WHERE TANK IS INSTALLED: /Q �n� "� �^� FARM TANK-YES NO ❑ (V I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOM N—SO SPECIFY tl O LD A. OWNERS TANK ID B B. MANUFACTURED BY: C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITE I 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 ❑ 1 pflpppCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S CAS.9 CAS.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A.TYPE OF ❑ 100118E WALlB) ❑3 SINGLE WAILED WITH EXT RIGA UNER ❑ 95 UNKNOWN SYSTEM ❑2 SNGLEWAUID ❑4 SECONDARY CONTAINMEP ❑99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL I 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GAIVANIZIDSIEEL :j 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RIBBERUNED ❑2 ALM LINING f j 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GIASSUNING ❑6 UNWED ❑95 UNKNOWN ❑IS UMNG MATERIAL COMPATIBLE WITH 100%MEIHANOL9 YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETNUNEWRAP ❑2 TARORASPHALT 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN E] 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 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALL--D A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS ST'EL 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 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,01 S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 AOOSE WELLS P S 4 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTITY OF3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION A II AGENCY 8 FACILITY ID N ? TANK ID M CURRENT LOCAL AGENCY FACILITY 108 APPROVED BY NAME PHONE M WITH AREA CODE /%P 7 PERMIT PERMIT APPRID DATE PERMIT EXPIRATION DATE CHECK• PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTS BY: FORM B(e-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE API CATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA I OCESSING COPY