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STATE OF CALIFORNIA WATER RESOURCES -.. <br /> FORM 'S': UNDERGROUND STORAGE T K O <br /> TANK TAPERMIT APPLICATION i <br /> NK FNY <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING WORMATION FOR EACH TANK. z <br /> r(( MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT F]5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK O <br /> ONE ITEM 2 WSW PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> r ( FACKJTY/8rTE NAME WHERE TANK 181NSTAWW. Q ,("�, FARM TANK-YES❑ NO W <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNovm-so sPECIFY 00 <br /> A OWNERS TANK 10 M B. MANUFACTURED BY: 00 <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OD <br /> f11. TANK CONTENTS IF(A.1).IS MARKED,COMPLETE ITEM C.IF(A.1).18 NOT MARKED,COMPLETE ITEM D. <br /> ' <br /> A. [:]1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. Ell UNLEADED 2 LEADED F-13 DIESEL <br /> 3 CHEMICAL PRODUCT �4 OIL <br /> El PRODUCT <br /> � 4 GASAHOL � 5 JET FUEL �6 AVIATION GAS <br /> 5 HAZAfMOUS E]80 EMPTY [:]95 UNKNOWN 2 WASTE 7 METHANOL ®99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> 'i D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> LHAZARDOUS SUBSTANCE STORED 6 CAS.M 6�-p CA.S.N: <br /> I <br /> ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN sox A.8,C.&D <br /> A.TYPE OF ❑ 1 DOUBLE WALL® Ej 3 WAE WALLED WITH EXTERIOR LINER ®95 UMO040WN <br /> SYSTEM E]2 SINGLE WALLED E:]4 SECONDARY CONTAINMENT E:199 OTHER <br /> i Q 1 STEEL/1RON [::]2 STAINLESS STEEL 3 Fl6EAGI.ASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TAN( M 5 CONCRETE Q 6 POLYVI7PL CHLOWE 7 ALUMINUM 8 1 OD%METHANOL.COMPATIBLE FRP <br /> MATERIAL <br /> El 9 Itfam El 10 GALVAIiZEOSTEEL 951MIacNOMn4 El 99 OTHER <br /> 1 RUBBER LIN® r-1 2 ALKYD LINING F-13 EPDXY LINING �4 PHENOLIC LINING <br /> LI F1 5 GLASS LANG F-�6 UMNI IN® �95 UNKNOWN <br /> E]ISANNG LMATERIA.COMPATI&E WITH 100%METHANOL? YES E]NO 99 OTHER <br /> 0.CMMM ❑ 1 POLYETH LE E WWW 2 TAR OR ASPIW.T 3 WK WRAP F-�4 RBMM REINFORCED FUSTIC <br /> PRQiECTIOM [3 5 CATMW PROTECTION 91 NOW 95 UNKNOWN Ej 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUNO,BOTH IF APPLICABLE <br /> A.SYSmTYPE A U 1 SUCTION A U 2 PRESSURE A a>GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> K COMITRUCTM A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A Q 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATIOV& A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A(DIM UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> i <br /> P i t VISUAL CHECK P i t INVENTORY RECONCILIATION P i a VADOSE WELLS P 8 4 ELECTRONIC MONITOR P i s GROUND WATER MONITORING WELLS <br /> I P i S PRECISION TESTING P i z PRESSURE TESTING P i 91 NONE 95 UNKNOWN P 3 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINMKi IN CALLOW INERT MATERIAL? DYES [:]NO <br /> i <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE <br /> i <br /> LOCAL AGENCY USE ONLY <br /> i <br /> COUNTY i JURISDtCTIlON• AGENCY i FACILITY ID i TANK ID i <br /> Ll EI I I <br /> j CUIUIENT AGENCY FACILITY H)1 APMOVED BY NAME PHONE•WITH AREA CODE <br /> i ems,e <br /> IPERMIT INllli[R PERMIT APPROVAL DATE PERMIT W4RATION DATE <br /> CHO"E T�i� <br /> AMOUNT 11UNCHARM ANL FEE CODE ECEIPT II BY: <br /> FORM B IA-29� 7M�MO UM M ow A1r�?ffmN a11l�ICAMK FORM'A', IA ItAt Sl6—FILED <br />