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STATE OF CALIFORMA WATER RESOURCES CONTROL BOARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK .- TANK PERMIT APPLICATION INFORMATION %/L• ± <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT ❑O RENEWAL PERMIT' [:]5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 1 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> � �B TANK REMOVED G <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: J CP c/C S c5+—` - FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SOSPECIFY <br /> A OWNERS TANK ID I B. MANUFACTURED BY: UCL <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: c,-J o <br /> IL TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. QI MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. - C. ❑ I UNLEADED D4f_EADED 7 DIESEL <br /> 0 CHEMICAL PRODUCT 0 OIL t, I pflppLKT ❑4 GASAHOL 5 JET FUEL Ej 0 AVIATION GAS <br /> 5 HAZARDOUS 00 EMPTY E]95 UNKNOWN 2 WASTE D 1 METHANOL 99 OTHER(DESCRIBE IN ITEM 0,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A CA.S.1 C.A.S.N: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D <br /> A TYPE OF 0 NUBtfWAUM O SINGLE WALLED WITH EXTERIOR UNfA 9S UNKNOWN <br /> SYSTEM 51 WALLED 1 SEC%UWCONTAWMENT 99 OTHER <br /> I SIEEUYION 2STAINESS STEEL 0FISEROIASS 1 STEEL CLAD WIFIBERCUSS REINFORCED PLASTIC <br /> B.TANK 5 wNum 0 POLYVMYLOLORDE I ALUMINUM 9 10AWTHNIOLCOMPATWITIP <br /> MATERIAL ❑ <br /> 9 BRONZE � 10 GALVANIZED 2E0 STEEL � UNKNONN 99 OTHER <br /> G INTERIOR ❑ I TUBBER LINED1 LINING 2 EPOKYUNNG /PHEHOUCUHINO <br /> LINING ❑5MASS LINING D 95 UNKNOWN <br /> ❑ SLWMG MATERALCOMPATIBIE WITH 100%METHANOL? YES ❑NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETNFIE WRAP �1 T OR ASNALT 7 YBNLWRAP 1 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 9i NONELi95 UNKNOWN 99 OIHEA <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U SU A U 2 PRESSURE A U 2 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S.CONSTRUCTION A U SINGLE W A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U A U 2 STAINLESS STEEL A U 7 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U I STEEL CLADWAFRP A U 8 10091 METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P / I VISUAL CHECK P 1 2 INVENTORY RECONCILIATION P 9 5 VADOSE WELLS P B I ELECTRONIC MONITOR P 6 5 OflOUND WATER MONITORING WELLS <br /> 8. 6 PRECISION TESTING P B I PRESSURE TESTING P I N P 6 95 UNKNOWN P 6 99 OTHER- <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> I. ESTIMATED DATE LAST USED(MOYYR) 2. ESTIMATED OUANTITY OF S,WAS TANK FILLED WITH <br /> /_ SUBSTANCE REMAINING IN �— INERT MATERIAL? YES L NO <br /> cl—Ilk c.-c� GALLONfi <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 6 SIGNAL URE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION N AGENCY/ FACILITY 10 1 TANK ID/ <br /> m = = 1 0 c__l I i I 9 1 5- 6 C) I �� <br /> CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE I WITH AREA CODE <br /> G< l <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE / <br /> CNFCKI PERy1T AMOUNT IURCHARGE AMT. FEECODEECEIPTI By: !/ <br /> C <br />