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STATE OF CALIFORNI# WATER RESOURCES CONTR*OARD ° <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. m <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 195 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT D 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED / 7 DN <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: L�X_ YN , FARM TANK-YES❑ NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 4! <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED 00 <br /> D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> F1 3 CHEMICAL PRODUCE 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD <br /> A TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEBUIRON 2 STAINLESS STEEL 3FIBERGLASS 4STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.MATERIAL E:] 5 CONCRETE 6 POLYVINYL CHLORDE 7 ALUMINUM 8 IW%METHANOL COMPATIBLE RSP <br /> ❑9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY UNING 4 PHENOUCUNING <br /> LINING ❑5 GLASS LINING 6 UNUNED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [�]NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENEWRAP 2 TAR OR ASPHALT 3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN D 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? EYES [1] NO <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&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# I AAGENCYI# FACILITY ID# / TAREA <br /> CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME <br /> PHONE M W LTDE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> b <br /> CHECK# PERMITAMOUNT SURCHA GE AMT. FEE CODE RECEIPT k <br /> BY; <br /> 7 <br /> FORM B(6-z9-eel THIS FORM MUST BE ACCOMPANiFD ACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HASBEENFILED <br /> DATA PROCESSING COPY <br />