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STATE OF CALIFORNIA WATER RESOURCES CONTROI ^OARD FORM 'S': UNDEkuROUND STORAGE TANK PROtxwiAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - Z I O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION n 7�PERMANENTLY CL G ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVED) I w ' FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z �j QO ,�bs �{i{•L L�� FARM TANK-YES❑ NO ❑ (V 1, I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN - B. MANUFACTURED BY' G YEAR INSTALLED (�"%� D. TANK CAPACITY IN GALLONS: .. [I. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ I MOTOR VEHICLE NEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ A OIL ❑ 1 PRODUCT ❑ A GASAHOL ❑ 5 JET NEL ❑ 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 6 CAS.N CAS.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF ❑ 1 DOUBLE WADED ❑3 SINGLE WALLED WITH EXTEROR LINER ❑%UNKNOWN SYSTEM ❑2 SWGIE WALLED ❑ A SECONDARY CONTAINMENT ❑ 99 OTHER r-1I STEIl/6gN ❑2 STAINES6 STEEL F-13 FIBERGLASS ❑/STEEL CLAD WIFIBERGUS6 REINFORCED PLASTICB.TANK MATERIAL ❑ ONOETE 5 CF-16 POLYVINYLCHLORIDE F-17 AUNINUM ❑B IOD%IIETHANOLODUPATIBLEFAP . ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑%UNKNOWN ❑ 99 OTHER G INTERIOR ❑ IBB I RER UN® ❑2 ALKYD UNNG ❑3 EPDXY LINING ❑1 PHENOLIC UNING LINING ❑5 QA% ' ❑6lkalN® ❑%UI11(HONM ❑IS LUNG MATBUAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑%OTHER D.CORROSION ❑ I POLYETHEIEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WIMP ❑A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 L9U(4OWN ❑%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 % UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE G MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 10D16 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U %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. ► t 1 VISUAL CHECK P t 2 INVENTORY RECONGLLATION • t 3 VADOSE WELLS P t 4 ELECTRONIC MONITOR ► { 5 GROUND WATER MONITORING WELLS ► { 6 PRECISION TESTING ► { 7 PRESSURE TESTING ► t 91 NONE ► { %UNKNOWN P { 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 WGALLON? NEER MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 1 JURISDICTION ImAGENCY P FACILITY ID{ TANK ID f� I I I —/ 7 . '� / A CURRENT LOCAL AGENCY FACILITY ID E APPROVED BY NAME PHONE I WITH AREA CODE Ml� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE G CHECKS PER WT AMOUNT SURCHARGE AMT. FEE CODE "CEIPTE BY: //.� q�� ` . FoRMe(6n-66) THIS FORM MUST BE ACCOMPANIED Br A FACILTTY/SITE APPUCATION, FORM 'A',UNLESS A CURRENT FORMA HASBEENFILFD L '� DATA PROCESSING COPY