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S"L"ATE OF CALIFORNO WATER RESOURCES CONTRONOARD •�:.�: <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM #94275B <br /> TANK TANK PERMIT APPLICATION INFORMATION ' <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWI O INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT Ej,3 RENEWAL PERMIT 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TANK REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: Lincoln Village We FARM TANK-YES[:] NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-11F UNKNOWN-SO SPECT <br /> A. OWNERS TANK ID A 715852 1 B. MANUF OWDT <br /> C.YEAR INSTALLED 1989 D. TANK CAPA ITY IN GALLONS: 12,000 allOns <br /> 11. 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 F-1 4 OIL © 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> E]5 HAZARDOUS 0 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&C.A.S.# C.A.S.W 8006619 <br /> Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,i D <br /> A.TYPE OF D I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON E]1 STAINLESS STEEL ©3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F-1 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING F-14 PHENOLIC LINING <br /> C.INTERIOR <br /> IN NC R FX 5 GLASS LINING F-1 6 UNLINED 0 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 10016 METHANOL? YES ❑NO 99 OTHER <br /> D.CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 0 5 CATHODIC PROTECTION QX 91 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 02 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S.CONSTRUCTION A U 1 SINGLE WALLED A @ 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 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 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 Q 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS 08 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 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 INERT MATERIAL? YES NO <br /> ON8 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF Y,ANDA THE EST KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE <br /> DSA\hD G_ �o1� tJSo� <br /> LOCAL AGENCY USE ONLY <br /> E <br /> JURISDICTION 8 AGENCYN F CI ID N TANK ID N <br /> = I I I �] El F1 I I I 1 I P I -dL[ I I I I <br /> AGENCY FACILITY ID• APPROVED BY NAME PHONE A WITH AREA CODE <br /> pPERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: <br /> FORM B(6-29.88) THIS FORM MUST BE ACCONIAIMED i RY/m AilRIC mN, FORM'A',UNLESS A FOM'X INS BEEN FILED <br /> 1 DATA PRO SING COPY 2 LOCAL AGENCY COPT COPY <br />