SITE INFORMATION AND CORRESPONDENCE

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-STATE OF CALI FO R N' ; WATER RESOURCES CONTR''BOARD »:.'•. FORM 'S': UND GROUND STORAGE TANK PROGRAM ' L TANK TANK PERMIT APPLICATION INFORMATIONo COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY F-1I NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS K to ONE ITEM ❑2 INTERIM PERMIT ED4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: ' S . S N A N FARM TANK-YES❑ NO'.V -PI. I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Tll �Zo3 t� k A. OWNERS TANK ID p B. MANUFACTURED BY: Cy) I C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: pp0 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A- i MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL I PRODUCT ❑ 4 GASAHOL ❑ 5 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&C.A.S.It C.A.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,S D A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN j SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER i I STE ARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WlFIBERGLASS REINFORCED PLASTIC I• B.TANK F-1 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 10696 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C.ARTERIOR I RUBBER UNED ❑2 ALM LINING F-13 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ® UNKNOWN ED 15 LINING MATERIALCOMPATIBLE WITH 10096 METHANOL? YES ❑NO OTHER-Ll CL __- _•,„•,__ D.CORROSION ❑ I POLYMILENE WRAP ❑2 TAA OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHDDICPROTECTION ❑91 NOW 95 UNKNOWN ❑ 99 OTHER IV, PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A 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 f A U 1 STEELARON A U 2 STAINLESS STEEL 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/FAP A U 8 100%METHANOL COMPATIBLE FIR: 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. 8 i VISUAL CHECK P 8 2 INVENTORY RECONCILIATIQN P $ 3 YADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELL5 S 8 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P $ 95 UNKNOWN P B 99 OTHER I VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE r-ST IMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF GALLONS 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS SEEN COMPLETED TINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, APPLICANT'S NAME(PAINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY E7RENTALAl,2E JURISDICTION Y AGENCY k FACILITY ID# TANK ID* ad z �� O AGENCY FACILITY Ip♦ APPROVED BYNAYS PHONE A WITH AREA CpDE M PERMIT APPROVAL DATEPEgM1T EIIPIRATION GATE PERMIT AMOUNT n lRCHAROE AVTFEE CODE P` --IPTI! BY;HIS FORM MUST BE ACCOMPANI BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED P-ROCE•SS!►1L;.GOPV� - - 4 - ._- �� - - - -•r�.'ii �-�I