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STATE OF CALIFORNitS WATER RESOURCES CONTRO00ARD FORM 'S': UNDE ROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION r COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. MARK ONLY ❑1 NEW PERMIT ❑3 RENEWAL PERMIT 0315 CHANGE OF INFORMATION ❑7 MANFJifLY CLO ONE ITEM 2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 09 7 w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 14%h , .;\ Z.4�17eL FARM TANK-YES NO ❑ Io 0 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I(� A OWNERS TANK ID N 0. MANUFACTURED BY: C.YEAR INSTALLED 1 0. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE REM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL ❑ 1 PRODUCT ❑< GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY E]95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEI.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.E CA.S.N: ! 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D A TYPE OF ❑ 1 DOIINEWALLED ❑3 SINGLE WALLED WTIHE%TFHORLINER ❑95 UNKNOWN SYSTEM ❑2 SNGLEWAILED ❑1 SECONDARYOWAINMEM - ❑99 OTHER ❑ I SIE8J ON ❑2 STNNUSSSIEEL ❑3 FIBERWM ❑i STEEL CLAD W/RBERGM REINFORCED PLASTIC B.TANK ❑5 NbNwm ❑6 POLWINYLCHLMN ❑7&LUINM ❑8 IW%UMWiOLCOUPATIBLEFRP MATERIAL. . - '.: ❑9 BRONZE ❑ 18 GALVANIZED STFH ❑%UMHOYlN ❑%OTf93i ❑1 IEIBBBI UNED ❑2 ALKYD LINING ❑3 EPOKYL99NG ❑i ME NOLIC LINING C.INTERIOR LINING ❑5.GUSSINNG ❑B UNLINED ❑%MICA ISUMNGiIATUDICOWATIBLFWIIHIW%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑I POLYETH.BEWRAP ❑2 TAR OR ASPHALT 1-13 VINYLMUP ❑A RBERGMFIONFOITCEDPLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPUCA13LE 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 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 A U 1 STEEL/IRON A U 2 STNNLESSSTEEL A U 3 POLYVINYL CHLORIDE IPVC) A U A FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL CLAD W/FAP A U B 190%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 9 1 VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P 9 3 VADOSE WELLS P 9 4 ELECTRONIC MONITOR P S 6 GROUND WATER MONITORING WELLS S 6 PRECISION TESTING P 9 7 PRESSURE TESTING F 9 91 NONE F 9 95 UNKNOWN ► 9 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTRY OF - - 8 WAS TANK RLLED WITH - SUBSTANCE REMAININ I IN O ONS WERT MATERIAL? ❑YES ❑ND THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT - APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 9 JURISDICTION i AGENCY 9 FACILITY ID N TANK IO N CURRENT LOCAL AGER CILITYWI APPROVED BY MAME PHONE I WITH AREA CODE U Li..Z i v PERMIT NUMBER PERMITAI"OVALDATE PERMIT EXPIRATION DATE CHECK) PERMIT AMOUNT is RCHARGE AML. FEE CODE EIPT11 IORLLelo-29-B6) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENRLED