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STATE OF CALIFORIviA WATER RESOURCES CON1xOL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION QO COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ D RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 0 TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: //S (/.- L,, ,f CTT- - FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK IDN ','"1-4- I B. MANUFACTURED BY: It C. YEAR INSTALLED a /L_. O. TANK CAPACITY IN GALLONS C7 c. II. TANK CqWENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB, PRODUCT C. [O_] I UNLEADED F] 2 LEADED IESEL ❑ 0 CHEMICAL PRODUCT ❑ 1 OIL C-] K GASAHOL E] 5 JET FUEL ❑6 AVIATION GAS C] 5 HAZARDOUS 80 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 CAS.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.L D A. TYPE OF ❑ 1 LE WANED ❑ D SINGLE WALLED WITH EYIERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SI ALLED ❑ /SECONDARY CONTAINMENT ❑ 99 OTHER LBI�ISTEEUIAON ❑ 2 STAINLESS STEEL 7 FIBERGLASS ❑ 1 STEEL GAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCIETE ❑ 6 POLYVINYL ClUDRDE ❑ 7 ALUMINUM ❑ E IDD%METHANOL COMPATIBLE FLIP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 0 99 OTHER ❑ G INTERIOR 1 R)BBERUNED ❑2 LINING ❑ 9 EPDXY LINING ❑ /PHENOLICUNING LINING ❑ 5 GLASS UNING 6 UMJNEO ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETMLENEWIW ❑2 T ASPHALT ❑9 VINYL WRAP ❑ /F18ERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION I NONE 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE I SUCTI N A U 2 PRESSURE A U B GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WAILED A U ]LINED TRENCH A U 91 NONE A U 9 UNKNO N U "OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE)PVC) A U I FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CgUGRETE— A U 7STEEL CUD W/FRP A U 81009Y METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U UNKNO A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. N 1 VISUAL CHECK P 2 2 INVENTORY RECONCILIATION P 2 9 VADDSE WELLS P ! ELECTflONIC MONITOR P ! S GROUND WATER MONITORING WELLS P • S PRECISION TESTING P N 7 PRESSURE TESTING P S _NONE_• P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED IMO/YR) 2. EST MATED QUANTITY OF ].WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? YES 7[::] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTEO A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY11 JURISDICTION E AGENCYII FACILITY ID IT TANK IO N _U_ _ 7 I'i I � I I ✓ U 1 CJ CURRENT LOC�AIL AOENCV FACILITY 10 N "PROVED BY NAME PHONE I WITH AREA CODE ` ^ PERMIT NUMBER PERMIT"PROVAL DATE =TIONDATE CHECKII PERYIT AYOUHT SURCHARGE AMT. FEE CODE RECEIPTII BY: x ,rm.RlA.Ia..' TNIRFDRM MIISTRF ACMIln IN,[n eve VIP..rry m,Te 1..1.111, Gn IGAA .A• uw eew ...,........