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STATE OF CALIFOR& WATER RESOURCES CONi*L BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INM)AMAT10N FOR EACH NK.TA H' +' , e MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑'S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED IC)q ) FACILITY/SI"NAME WHERE tANk IS INSTALLED: ; �,�� -,� _ , �� _sZ> FARM LANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN–50 SPECIFY A. OWNERS TANK N)M B. MANUFACTURED BY: F C. YEAR INSTALLED �. D. TANK CAPACITY IN GALLONS: 11. TANK C TENTS IF(AL1),IS MARKED,COMPLETE ITEM C.IF(AL1),18 NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED IL–] 2 LEADFD �1 JF%L Ela dEMICAL OROOI1Ci ❑A OIL ` I PRODUCT ❑ A GASAHOL ❑5 JET FUEL 8 AVIATION GAS ❑S HAZARDOUS M EMPTY ❑95 UNKNOWN ❑ 2 WASTE 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,RFI OWI 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.1 CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,N,C,S D A.TYPE OF ❑ I WALLED ❑3 SINGLE WALLED WITH DITERIOALINER ❑95 UNMOVIN SYSTEM i A11B1 A SECONDARYCONTARIMENT ❑99 OTHER I SRTLIRON I.TANK E]2 STAINLESS STEEL ❑3 FIBERGLASS 1 STEEL CLAD WIFIBERGASS REINFORCED PLASTIC 8 POLYVINYL CHLORIDE �� EJ9 I'm ❑ ❑ 7 ALUMINUM ❑e 108%METHANp.IbMPAiIOLE ERP ❑9 mm 18 GALVANIZED STEEL ❑95 UNKNOM 99 OTHER (, INTERIOR ❑ I BUBSERLINEO ❑2 LINING F]3 EPDXY LNING E] 1 PHENOLIC LINING LRRNO ❑S FKAS9tw ee UNUNEO ❑95 UNKNOWN B UMAI MATERIAL COMPA118LE WITH IMA UETHANOL7 ❑YES ❑NO ❑99 OTHER F SIGN 1POLVER9ENEMlAP ❑ LIR ASPHALT ❑3 VINYL WRAP ❑ 1 FIBERGLASS REINFOBCEO MASTIC TION ❑3 CATHOOICPLOMPON Ef91 NONE ❑95 UNKNOWN ❑99 OTHER -- IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,NOTH IF APPLICABLE A.SYSTEM TYPE A U I SMHON A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE AAQ-54N—KN-OWN, A U 99 OILIER I.CONITNUCT10N A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 31_95 UNKNOWW_, A U 99 OTHER A U -f STItAdIRON, A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A PBERDLASS PIPE A U 91 NONE C.MATERUIL A U @CONCRETE A U 787EELCLADW/FRP A U B IW%METHANOL COMPAIISLE TRIP A U 9 GALVANTEPO STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE 0 FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P • 1 N9UAL CHECK ► 1 2 INVENTORY RECONCILUTION 11 1 3 VADOSE WELLS P B A ELECTRONIC MONITOR P 9 5 GROUND WAIER MONHORINO WFLI.S ► 19 PRECRIION TESTING ► / 1 PRES9LINE TESTINGP S 91 NONE" ► • 95 UNKNOWN P • 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTNMTEO DATE IAST USED(M07YRI 2. EST IMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON• INERT MATERIAL? [_jYFS E] NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PPoNTEO A SIGNATURE) DATE LOCAL AGENCY US ONLY COUNTY 1 JURISDICTION I AGENCY F FACILITY 101 TANK ID 1 CURRENT LOCA AGENCY FACILITY ID 1 APPROVED BY NAME PHONE 9 WITH AREA COO! P[RMR NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE - - CHECK/ PERMIT AMOUNT •URCHARGE AMT. FEE CODE RECEIPT I 1 / funm a RI 29-e9) TH I FORM MUST IE ACCOMPANIED IT A FACILRY/•ItE APPLICATION, FORM W,UNLESS A CURRENT FORMA' NAS IEEN FILED