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STATE OF CALIFORA WATER RESOURCES CONTRINOARD ffl' <br /> b"). <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM #94275C <br /> TANK PERMIT APPLICATION INFORMATION TANK A SEPARATE FORM WITH THE FOLLOWI INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM El 2 INTERIM PERMIT 4 AMENDED PERMIT8 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Lincoln Villdft1g, INS I @kRM TANK-YES E:] NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1. <br /> A. OWNERS TANK ID N 715852 1 B. MANUFACVIJ14 el. ' OWDT <br /> C.YEAR INSTALLED 1989 Di iW4l%pprtrtppi'�b/Ih���&p6sHEALTH 12,00 allOns <br /> 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),18 NOT'MA11YCED,•1C61MPL D. <br /> A. ® 1 MOTOR VEHICLE FUEL 7 2 PETROLEUM B. C. ©1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F_�4 OIL © 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN 2 WASTE El 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.N: 8006619 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF O I DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM [:]2 SINGLE WALLED 4 SECONDARY CONTAINMENT F]99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL a 3 FIBERGLASS F__j 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK Q 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM ❑8 1 OD%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED E]2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ®5 GLASS LINING El 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES E]NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP [:]2 TAR OR ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION EX 91 NONE 0 95 UNKNOWN [j 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 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 8.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 W4 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 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 MUST BE CIRCLED. <br /> P 8 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS E)S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 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 OF3.WAS TANK FILLED WITH <br /> GALL <br /> SUBSTANCE REMAINING IN INERT MATERIAL? YES [:]NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY JURY,AN T E OF Oy KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) C DATE G <br /> N 0+ !II <br /> LOCAL AGENCY USE ONLY <br /> E <br /> JURI8DICTION N AOENCYN IDN TANK IDEE I I I �] EI I / � FM I 1 1 151 <br /> GENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> ZC PERMIT APPROVAL DATE PERMIT EXPIRATION DATEPERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: <br /> FORM B(6-29-86) THIS FORM MUST E ACCOWIA: ::Appm=K FORM'A',UMl=A F='A' MASBEENFILED <br /> 1 DATA PRO SSING Y 2 LOCAL AGENCY COPW COPY <br />