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STATE OF CALIFOR& WATER RESOURCES CONIk BOARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM f�r� <br /> TANKTANK PERMIT APPLICATION INFORMATIONA: ' <br /> COMPLETp A IEPARAr9 PORM WITH THE POLL WIN INF MAtION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT Ej 3 RENEWAL PERMIT CHANGE OF INFORMATION Ej 7 PERMANENTLY CLOSED TANK T <br /> ONE MEM 2 INTERIM PERMIT Ej 1 AMENDED PERMIT EIR TEMPORARY TANK CLOSURE EJB TANK REMOVED <br /> U9 <br /> FACILItY/it"NAME WHERE TANK Ib INStALLED: t) s 5%=/ �,{1,:: > > FARM TANK-YES NO <br /> /.J - / ,ss /'C c/. <br /> 1. TANK DESCRIPTION coMPLEtE ALL ITEMS-IF UNKNOWN—80 SPECIFY J <br /> A. OWNERS TANK ID! % 3 B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: i�> ;�.��� �c <br /> 11. TANK NTENTS It(A1),IS MARKED,COMPLETE ITEM C.IF(A1),18 NOT MARKED,COMPLETE ITEM D. <br /> A. ; 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. - C ❑ I UNLEADED u 2 LEADED O DIESEL <br /> F1 S CHEMICAL PRODUCT ❑1 OIL O R PRODUCT /GASAHOL 5 JET FUEL 1 AVIATION OAS <br /> S HAZARDOUS AO EMPTY 95 UNKNOWN Ej 2 WASTE 0 7 METHANOL ❑99 OTHER(DESCRIDE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED A CA.S.R CA S,X: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A 8,C.S 0 <br /> A TYPE OF ❑ 1 *kLED S SINGLE WALLED WITH ENTER011 LINER 095 UNKNOWN <br /> Sys 111 WALLED 1 SECONDARr COMAINMENT �99 OTHER <br /> STEEURON 02 STAINLESS STEEL Ej3FIBERGLASS 01 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> 8.MMATERIAL ❑5 CONCRETE ❑9 PO LYRNYL 04oRIDE El 7 ALUMINUM 0 0 INA .IETFUNOL COMPATIBLE FRP <br /> 9 MIE O 10 GALVANIZED STEEL E 95 UNKNOYM EJ 99 OTHER _ <br /> C, INTERIOR ❑ 1 RUBBER LINED 2 LINING 0 3 EPDXY LINING Ej 1 PHENOLICUMNG <br /> IN" ❑S Mm uR11D /UNLINED Lj 95 UNKNOWN <br /> El B LINING MATERIAL COMPATBU WITH 100%METHANDL7 YES 0 No ❑99 OTHER <br /> D. CORROSION ❑ 1 POLYEII DCIII RAP 02 LTR ASPHALT O 3 WMWW 01 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CAUKOICIINGTECTION " 91 NONE M UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE ` --1111 NOWN A U 99 OUTER <br /> 8.CONSTRUCTION A U 191NOLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE 95-NKNOWN, A U 9qWN, <br /> 'S U I STEEL/I --'> A U 2 STAINLESS S1EEL A U 3 POLYVINYL CHLORIDE(PVCI A U / rIBEnGLASB PC. TFE A U 91 MATES A U 8 CONCRETE A U 7 SIEELCLADW7rRP A U 8 ID0%METHANOLCOMPATIBLFr <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P • 1 N9UAL CHECK P 1 9 INVENTORY FIFCONCILIATION h ! 3,!ADOSE WELLS P e / ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WFU S <br /> P 1 !PRECISION TESTING P 1 7 PRESSURE TESTING 'IF ! 91 _NONE P 8 95 UNKNOWN P 1 99 0111ER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.E911A IW DATE RAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRFrT, <br /> APPLICANT'S NAME(PRINTED 6 91GNATUREI DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 1 JURISDICTION 1 AGENCY A FACILITY 101 TANK ID N <br /> CUIIR[M LOCAL AGENCY fACKITT 101 APPROVED BY NAME PHONE P WITH AREA CODE <br /> %-i2 i 5 - 5 <br /> PE <br /> NUMBER PERMIT APPROVAL DAT! PERMIT EXPIRATION DATE <br /> CHOCK 0 PfRMR AMOUNT IURCHAR02 AMT. FEE CODE ECEIPT 1 <br /> BY: r <br /> FORN1 B 0129.811 THM FORM MUTT IE ACCOMPANIED IT A FACK111111TE APPLICATION, FORM 'A%UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> —A nn nno� "L, <br />