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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z <br /> 6 47 <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ERMANENTLY CLOSED TANK <br /> ONE ITEM Ej 2 INTERIM PERMIT El 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED d <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 13 6A 1 . Mar FARM TANK-YES❑ NO <br /> po <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED L.-'X D. TANK CAPACITY IN GALLONS: <br /> If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY ED95 UNKNOWN 2 WASTE El 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N ILIA. CA.S.N: <br /> I11. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.&D <br /> A.TYPE OF ❑ 1 BLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM El <br /> E]4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 10096 METHANOL COMPATIBLE FAP <br /> 9 BRONZE ';'"1' E] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR <br /> 1 RUBBER LINED E]2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> , <br /> LINING ❑S GLASS FZOfNUNED 95 UNKNOWN v <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES E] NO �99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP [:]2 T R OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [:]5 CATHODIC PROTECTION 1 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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.MATERIAL '+ A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1 OD%METHANOL COMPATIBLE FAP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM ROUST BE CIRCLED. <br /> � PS�VISUAL�CHECK� P�" INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS <br /> PRESSURETESTING 91 NONE P S ,I UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? r—1 YES El NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION @ AGENCY# FACILITY ID# TANK ID# <br /> ME d �, a10101 <br /> CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE kERMIT EXPIRATION DATE <br /> CHECK M PERMIT AMOUNT SURCHARGE AMT. FEE CODE 9ECEIPT M BY: <br /> • FORM B(6-29-88) THIS FORM DUST BE ACCOMPANIE'UW'A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A -04ENT FORMA' HAS BEEN FILED <br /> 2ATA. PRnrlcCPl"'- r`nnw <br />