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am <br /> 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!N MAT]ON FOR EACH TANK. � <br /> IC <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: I :Zoo/-) FARM TANK-YES❑ NO 4b. <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-.-SO SPECT <br /> A. OWNERS TANK ID qQ. MANUFACTURED BY: 00 <br /> G. YEAR INSTALLED ( / 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 P OLEUM B. G. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW( <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&O.A.S.# C.A.S.#: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD <br /> A.TYPE OF ❑ 1 DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 NDARYCONTAINMENT [71 99 OTHER <br /> I STEELIIRON NLEEL ❑3 FIBERGLASS E]4 STEEL CLAD WIFTERGLASS REINFORCED PLASTIC <br /> B.TANK ESS ST <br /> ❑5 CONCRETE 6 <br /> MATERIAL NYL CHLORIDE 7 AL M 8 10046 METHANOL COMPATIBLE FRP <br /> 9 B 10 GALVANIZED STEEL 5 UNKNOWN 99 OTHER <br /> C. rNtRIOR <br /> i R ER LI ❑ 2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHEN INING <br /> LINING F-15 GLA ❑6 UNUNEGL�j�UNKNOWN <br /> �' ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER <br /> D. CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 N P ❑4 FIBERGUM REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ss UNKNOWN El 49 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH OF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 5 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 k-0)5 UNKNOWN A U 99 OTHER <br /> A U 1 STEELPRON 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 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST 13E CIRCLED. <br /> P S 1 VISUAL CHECK P 3 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P S b ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED/(4OfYR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES ONO <br /> �v <br /> f <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 8 SIGNATURE) DATE i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION N AGENCY# FACILITY ID# TANK ID N <br /> ❑ L I I LJ E lJ <br /> CURRENT LOCAL AGENCY FACILITY SID 0 APPROVED BY NAM PHONE A WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE RM EXPIRATI DATE <br /> � t <br /> CHECK 0 PERMIT AMOUNT SURCHARGE AMT, FEE CODE RECEIPT 0 BY: <br /> ' � A <br />�� FORM B($-29-BB) THIS FORM MUST BE ACCOMPANIED FACILrrY/SrTE APPLICATION, FORM W.UNLESS A ENT FORMA' HAS BEEN FILED J1 <br />