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STATE OF CALIFOF* WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM Go TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING IN MATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ I RENEWAL PERMIT EH5CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED U FACILITY/BITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO ❑ 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK ION C B. MANUFACTURED BY: LC el— C. l—C.YEAR INSTALLED 6614 D. TANK CAPACITY IN GALLONS: YO L9 Cl - c II. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A•1).IS NOT MARKED,COMPLETE ITEM D. A EZ�l MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. D1 UNLEADED ❑ 2 LEADED ❑ 0 DIESEL ❑S CHEMICAL PRODUCT ❑ A OIL 1 PRODUCT ❑N L9A.SAHOL ❑5 JET FUEL ❑ 8 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 1 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.A D A TYPE OF ❑ I DDWWALILD ❑7 SINGLE WALLED WITH EXTERIOR um ❑95 mm" SYSTEM FD 2 SINGLE 111 ❑ R SECOIOARWCONTAINMENT ❑99 OTHER I SIEEUMON ❑2 STNNUSSSTEEL ❑ I FIBERGLASS ❑1 STEEL CLAD W/FIBERGU.SS REINFORCED PLASTIC 8.TANK ❑5 CONDETE ❑N POLYVINYLCADADE ❑ 7 ALUMINUM ❑ N IWiLMEFHANOLCOMPATIBLEFRP MATERIAL ❑9 8fi0N2E ❑ 10 CAL4AM2E0 STEEL E].95 UNKNO%M ❑ 99 OTHER C.INTERIOR ❑ I RUBBER UNM ❑ 2 AIM LINING ❑ I EPDXYUNING ❑/PHENOLIC LINING LINING ❑5 GLASS LUNG NED ❑95 UNKNOWN ❑ 6 LINING MATEML COMPATIBLE WITH IOD%MEIHAIKILT ❑YES ❑NO E]95 OTHER D.CORROSION ❑ I POLYFIIEETEWRAP [::] T T ASPHALT ❑I VINR.WRAP ❑ A RBEFIGLASSREIWORCEDPLASTIC PROTECTION C]5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEI 64 A U 2 PRESSURE A U I GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U - INGLE W D A U 2 DOUBLE WALLED A U S LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 'STEEL71 A U 2 STAINLESS STEEL A U D POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U B IDDM 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 B 1 VISUAL CHECK P 1 2 INVENTORY RECONCILIATION P / D VADOSEWELLS P S A ELECTRONICMONITOR P 1 5 GROUND WATER MONITORING WELLS L 1- P /. 1 PRECISION TESTING P I T PRESSURE TESTING P N O P 1 95 UNKNOWN P 1 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2.ESTI MATED QUANTITY OF _3WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERAL7 ❑YES ❑ NO I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE V LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID NTANK ID S () CURRENT LOCAL AGENCY FACILITY ID P APPROVED BY NAME PHONE E WITH AREA CODE Z civ ca S i PERMIT NUMBER PERMITAPPROVALDATE PERMIT EXPIRATION DATE I CHECK PERMIT AMOUNT 6URCHAflOE AMT. fEF COD! q'TE CEIPT/ OY: .......n..nn.a• wit PGRu uI PQT OC IM.1u0A HI[D PY A[API,RV! .