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STATE OF CALIFORNI& WATER RESOURCES CONTROOARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> e <br /> TANK TANK PERMIT APPLICATION INFORMATION ` <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 10 <br /> MARK ONLY _� - NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 6 q <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1, l.I, r ��c� FARM TANK-YES❑ NO PQ 41kb <br /> C" <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 1 C" <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: �� 1 i "4 <br /> C. YEAR INSTALLED ) g a D. TANK CAPACITY IN GALLONS: 0 <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. X 1 MOTOR VEHICLE FUEL [K 2 PETROLEUM B. C R] 1 UNLEADED ❑ 2 LEADED 3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑4 OIL F-11 PRODUCT F-� 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS E] 80 EMPTY ❑ 95 UNKNOWN E]2 WASTE 7 METHANOL Ej 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 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ® 1 DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER F�j 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD W/fiBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE F-� 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER <br /> s <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C. INTERIOR <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [::] NO E] 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ® 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION ❑ 91 NONE E] 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 AQ 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSO'S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER Lc A k •� ^T_ <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? YES NO <br /> �v <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPJLLIIC�A,NT('S NAME(PRINTED&SIGNATURE) =///// <br /> GL-11 <br /> LOCAL AGENCY USE ONLY <br /> a <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> m1 - .3 1 53 [ 01 OTO <br /> 11 <br /> CURREN1T LOCAL AGENCY FAC ITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> L <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: <br /> U FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIEM A FACILITY/SITE APPLICATION, FORM `A',UNLESS A RENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />