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STATE OF CALIFORNe WATER RESOURCES CONTR•BOARD <br /> FORM 'S' UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. Z <br /> IC <br /> MARK ONLY .. ❑ i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED / <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: �, til �� fARM TANK•YES❑ NO N <br /> 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY <br /> CO <br /> A. OWNERS TANK IDR B. MANUFACTURED BY: C� <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: o <br /> n d <br /> 11. TAN ONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),I NOT MARKED,COMPLETE ITEM D. lz <br /> A. 1 MOTOR VEHICLE FUEL F� 2 PETROLEUM 8. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> f7 3 CHEMICAL PRODUCT [D 1 OIL 1 PRODUCT ❑< GASAHOL [] 5 JET FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS E:] 80 EMPTY [:1 95 UNKNOWN 2 WASTE ❑ 7 METHANOL E:]99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.8: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLEWAILFD E]1 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEUIRON 0 2 STAINLESS STEEL 3 FIBERGLASS 1 STEEL CUD WiFIBERGLASS REINFORCED PLASTIC <br /> B.MATERIAL" ❑ 5 CONCRETE El 6 POLYVINYLCHLORIDE 7 ALUMINUM 8 1OD%METHANOL COMPATIBLE FRP <br /> ',i El 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR ❑ I RUBBER UNED 2 ALKYD LINING 3 EPDXY LINING 1 PHENOUC UNING <br /> LINING ❑ 5 GLASS UNING 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL? YES ONO 99 OTHER <br /> D.CORROSION ❑ I POLYSAME WRAP 2TM OR ASPHALT 3VINYL WRAP /FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U < FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S < ELECTRONIC MONITOR P 8 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 8 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH <br /> GALLONS <br /> SUBSTANCE REMAINING IN INERT MATERIAL? YES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Y JURISDICTION Y �AGGENCY# FACILITY ID Y TANK ID M <br /> L-LJ�I 5 <br /> CURRENT LOCAL AGENCY FACILITY ID Y APPROVED BY NAPE PHONE Y WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> 5 <br /> 1 CHECK I PERMIT AMOUNT -z"0_4 1 <br /> �RCHARGE AMT. FEE CODE EIPT 1 BY;�/A <br /> -�, FORM a(6-29-e8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FO RM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED <br />