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STATE OF CALIFORNIAwe WATER RESOURCES CONTROL..,OARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .c MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 ERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED O 14 FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (Tl 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY QO A. OWNERS TANK ID N B. MANUFACTURED BY: K N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 49 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A_ ❑ 1 MOTOR VEHICLE FUEL ❑ ETROLEUM R. C [D1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ ROOUCT E]4 GASAHOL [j5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS [-]80 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.# 1NAs'r& W, III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A. TYPE OF ❑ 1 UBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SI LE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER STEEUIRON ❑2 STAINLESS STEEL M 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE E] 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBE UNE ❑1 D LINING ❑ 3 EPDXY LINING ❑4 PHE C 1 LINING ❑5 GLASS LINING 6 UNLINED ❑95 UN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ND ❑99 07.E D.CORROSION �YETHLENE WRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCE PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDE OUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 NKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 10D%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. 1 B 1 VISUAL CHECK P 4 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER 1V VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INOALLONB 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY y COUNTY M JURISDICTION N AGENCY U FACILITY ID N TANK ID# EjEl LLI ImI1010106 CURRENT LOCAL AGENCY IL TY I0 APPROVED BY NAME PHONE N WITH AREA CODE 1 PERMIT NUMBER /vv. I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ,\ CHECK• PERMITAMOUNT / SURCHARGE AMT. FEE CODET"CEIPTp `Vyb v FORv BI62969) THISFORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSACURRENT FORMA ;iAS BEEN FILED