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STATE OF CALIFOR& WATER RESOURCES CONOL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM -.. TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A BEPARAtE PORM WITH THE POLLOWINO PORMATION POR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMITu "CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑I AMENDED PERMIT ❑B TEMPORARY TANK CLOSURE ❑3 TANK REMOVED Q 9 FACILIEY/fItE NAME WHERE TANK IS INSTALLED: _.]SSG/ �G ffimis� ss - FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN—SO SPECIFY J A. OWNERS TANK ID F R MANUFACTURED BY: uK C. YEAR INSTALLED �.� D. TANK CAPACITY IN GALLONS: UJ cp 11. TANK CONTENTS It(AJ.10 MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A ❑I MOTOR VEHICLE FUEL ❑2 PETROLEUM❑ C. ❑ I UNLEADED LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 1 OIL 1 PRODUCT ❑/GASAHOI ❑5 JET FUEL ❑8 AVIATION OAS ❑ 5 HAZARDOUS ❑00 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 A CAS.F C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C.A o A TYPE OF ❑.0MINALLY1 ❑3 SINGLE WALLED MTH E%TEROI MR ❑95 UWN W SYStem ❑2 SPIUE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER S. TANK ❑ 1 MIN" ❑2 STAIWESSSTEEL ❑3 FIBEROUSS ❑A STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑S CONOIEIE ❑I POLYVINYLCHLORIDE ❑l ALUMINIM ❑110"MORANOLCOWATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR E) I RUBBER L9 B1 ❑��2 URM ❑3 E VININIG El PHENOLICUMNG LINING ❑5 am t"NG Ll^uNUNEO ❑95 UWNOWN ❑B UIN O MATERIAL MWARNU WITH 100% l AS ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETILENEWRAP ❑2 ORASRULT ❑3V9MWRAP ❑T FIOMMREWORCED PLASTIC PROTECTION ❑5 CADIOOIC PROTECTKIN ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U 1 auanoW— A U 2 PRESSURE A U 3 GRAVITY A U BI NONE A U UNKNOWN U 99 OTHER S.CONSTRUCTION A I SIN AUID A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKN A U 99 OTHER 1 SiEEl/IRON] A U 2STAWLE9S STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE G MATERIAL A U A ALUMINUM A U E A U ?STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 0 GALVANIZED STEEL A 95 OWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 9 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 9 1 VISUALCFIECK P 9 2 INVENTORY RECONCILUTION 0 9 3 VAOOSE WELL9 P 9 9 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WFLLS P 9 9 PRECISION TESTING P 9 1 PRESSURE TESTING 91 NONE ► 9 95 UNKNOWN 0 9 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. E9TIMAI tU DATE LAST USED(MO/YRI 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑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 SIONOURE) DATE LOCAL AQENCY USE ONLY COUNTY S JURISDICTION S AGENCY 9 FACILITY ID 0 TANK ID 9 CU d y 'Lf � C) p � ICURRENT LOCAL AGENCY FACILITY W I APPROVED 9Y NAME PHONE E WITH AREA CODE S PERMIT APPROVAL DATE PERMIT EKPIRADON DATE E PERMIT AMOUNT 9URCHARME AMT. FEE CODE RECEIPT 1 9r: row R RI 29,RA) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM W HAS SEEN FILED M ��