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0 0 STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM '=" ' TANK ''''�`�'� ' ' :-- TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ O RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDONE ITEM ❑2INTERIM PERMIT ❑ 1 AMENDEOPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVE(FACILITY/BITE NAME WHERE TANK IS INSTALLED: /O(o (rJ, , , y S't- FARM TANK.YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS•IF UNKNOWN-80 SPECIFY A OWNERS TANK IO/ ;r 1 B. MANUFACTURED BY: �lC C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS 0 0C7< h�— II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A �l MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. j C. ❑ 1 UNLEADED 2 LEADED ❑ 9 DIESEL ❑O CHEMICAL PRODUCT ❑ 1 OIL ❑ 1 PRODUCT ❑ T GASAHOL ❑ 5 JET FUEL ❑ e AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER IDESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.1 C.A.S.9: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ I pBJBLE WALLED ❑0 SINGLE WALLED WITH EXTERIOR LPER ❑ %UNKNOWN SYSTEM 2 SINGLE WAILED ❑ /SECONDARY CONTAINMENT ❑ 99 OTHER �I STHURDN ❑2 STA7NESSSTEEL ❑7 RSEROIA.SS ❑ 7 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ !POLYWIRLCILORIDE ❑7 ALUMINUM ❑ 6 107AUSKMOLOOMPATELEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL [].%UNNNOWM ❑ 99 OTHER ❑ G INTERIOR I FUSSER UNEB El2 UNNG F10 EPDXY UNNG ❑ /PHENOLCUNINO LINING ❑5 GLASS LUNG 6 IEAINED ❑ %UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE MTH 100%METHANOL? []YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETRUMWRAP ❑2 WOR ASPHALT ❑2 VIM'LWMP ❑ I FIBERGIASSREINFORUDPLASTIC PROTECTION ❑ 5 CATH000 PROTECTION 0/91 NDNE ❑%UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A "i SUET A U 2 PRESSURE A U 9 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1�04GUE W A U 2 DOUBLE WALLED A U B LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U STE A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE IPVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U E CONCRETE A U 7 STEEL CUD W/FRP A U t 100%METHANOLCOMPATISLE 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 t IVISUAL CHECK ► INVENTOR! NCIUATION P t 9VADOSE WELLS P / A ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P ;� TESTING P t 7 PRESSURETESTING P t 91 NONE P t 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MOIYR) 2.ESTIMATED QUANTITY OF 1 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. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION t AGENCY 1 FACILITY ID E TANK ID 1 T77 CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE F WITH AREA COO! ,/.%//6 n io I,- PERMIT rPERMIT NUMtER PERMIT APPROVAL OAT! PERYITEXPI •ONDA7! CHECKI PEflYIT AMOUNT tURCHAflOE AMT. FEE CODE RECEIPT/ 0T: de