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STATE,O.F'CALIFORN WA TER RESOURCES CONTI*BOARD ;FORM 'S'' , UNDERGROUND STORAGE TANK PROGRAM s TANK PERMIT APPLICATION INFORMATION K.'.:";;, .•,; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF A710N FOR EACH TANK. MARK ONLY: ~,•❑ I NEW PERMIT . ❑3 RENEWAL PERMIT. CHANGE OF INFORMATION ❑7 P ENTLY CL K I O ONE ITEM. .i ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: . n(Ap FARM TANK-VES NO ❑ I O / 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY lJ co A, OWNERS TANK IDE B. MANUFACTURED 8Y: C.YEAR INSTALLED - - D. TANK CAPACITY IN GALLONS: Q 11. TANK CONTENTS IF(A.1),19 MARKED,COMPLETE ITEM C.If(A.1).IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 9. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ O CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 50 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.E CA.S.E: 111: TANK CONSTRUCTION MARK ONE ITEM ONLY IN 80X A,B,C,&D A TYPE OF. ❑T,DOUBLE WWW ❑3 914GLE WALLED WITH EXTERIOR UNEP ❑95 UNKNOWN SYSTEM ❑ 2 SINGLEWAULD ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1.STEEUIRON ❑2 STAINLESS STEEL r73 FIBERGLASS ❑4 STEEICUDWIFlBETMSLASS flEINFOflCED PLASRC B.TANK ;❑5 CONCRETE ❑6 FOLYWNYLCHLORDE ❑ 7 ALUMINUM ❑S IW%METRANOLCOUPATISLEFRP MATERIAL,,' -:,:. ❑.9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING; �r.'❑ 5.GUSSUNING ❑6UNUNED ❑ 95 UNKNOWN ' . '❑ IS LINING MATENMLOOMPATIBLE WITH LOOS MET"L7 [:]YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1,POLYM ENEWRAP ❑2TABORASPMALT ❑9WNfLWFlAP ❑4 FIBERGLASS REINFORCED RASTIC PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVIN A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERL41 'A U 5 ALUMINUM A U S CONCRETE A U 7 STEELCLAD W/FRP A U B 100%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 SECONDAFTY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS S B PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTIN OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [DYES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEFUURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPUCANT'S NAME(PRINTED&SIGNATURE) GATE LOCAL AGENCY USE ONLY COUNTY11 JURISDICTION# AGENCYS FACILIFAC/I/LITY�IIDDJf TANK IDE 7T I r CURRENT LOCAL AGENCY FACILITY 10 APPROVED BY NAME PHONE#WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE -2 -89 CHECK# PER SURCHARGE AMT. FEE CODE ECUPTA BY: . w�S FORM e(S•2&BBI THIS FORM MUST BE ACCOMPAN Y A FACILITY/STTE APPLICATION, FO R M 'A',UNLESS A CURRENT FORMA' HASSEEN FILED