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STATE OF CALIFORMA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK '' ` ` TANK PERMIT APPLICATION INFORMATION : COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑G RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSE ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED o FACILITY/SITE NAME WHERE TANK IS INSTALLED: J q- (c s FARM TANK-YES❑ NO I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK IDI j B. MANUFACTUREDBY: u/(— C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: S�, 11. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A [21MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED L-- ❑G CHEMICAL PRODUCT ❑1 OIL LE -r.- T ❑I GASAHOL ❑5 JET FUEL ❑S AVIATION GAS ❑5 HAZARDOUS ❑ SO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(OESCRIBE IN HEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED S C.A.S.I C.A.S.I: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A.TYPE OF ❑ 1 WALLED ❑7 SINGLE WALLED VAIN EXTERIOR LNEA ❑9S UNKNOWN SYSTEM tI WALLED E]/SECONDARY CONTAINMENT ❑99 OTHER I STEEUMON ❑2 STAIN ES5S1EEL ❑7 FIBERGLASS ❑1 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑S CONCPkIE ❑6 POLYNNYLOILMDE ❑ 7 AUAIINUM ❑ 9100%LCHANOL COMPATIBLE RP ❑ El E]9 BRONZE 10 GALVANIZED ❑%ZED STEEL UNKNOWN 99 OTHER ❑ G INTERIOR 1 PASSE mm ❑ UNING ❑ 2 EPDXYUNNG ❑1 PI EWWUNNO GL LINING ❑S ASS UNNG EE16 UNJNEO ❑95 UNKNOWN ❑ SLNNG MATERML COWATELE WITH 100% 7 ❑YES ❑NO ❑ 99 OTHER L CORROSION ❑ I PDLYEUUKWRAPR19-it giAWMI ❑7 VWL WRAP ❑ /FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CAIHOGIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U SU A U 2 PRESSURE A U 2 GRAVITY U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U D A U 2 DOUBLE WALLED A U 2 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A 1 STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U IT CONCRETE A U 7 STEEL CLAD W/FRP A U 6 IC METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 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 t I VISUAL CHECK F I 2 INVENTORY RECONCILIATION P t 5_Y LL WES ► t 9 ELECTRONIC MONITOR ► t 5 GROUND WATER MONITORING WELLS P I. t PRECISION TESTING P t T PRESSURE TESIINO P S 91 NO P t 95 UNKNOWN P t 99 OTHER Vi. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ES71MAIED DATE LAST USED(MO/YR) 2. ESTIMATED OUMT11Y OF IW WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? E-'11i1i k wUv✓ l �- GALLONS ❑YES Cfr'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 SIGNAI URE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION I AGENCY I FACILITY ID I TANK ID 9 > 5- -5 10 1 a I s CURRENT LOCAL AGENCY FACILRY•ID I APPROVED tY NAME PHONE F WITH AREA CODE �J r3 S cJ PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE �/ J CNICKI PERMIT AMOUNT �URCHAAGE AMT. FEECODE '_. CEIPTI BY: ✓l