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STATE OF CALIFORNIA WATER RESOURCES CONTROWARD FORM 'S': UNDE ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION 6111§L(tt A 9EPAhAtE FORM WITH THE FOLLOWING rORMATION FOR EACH TANK. -a MARK ONLY ❑ I NEW PERMIT ❑3 RENEWALPERMIT DYCHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED �' FACILITY/SITE NAME WHERE TANK IS INSTALLED: -Z V Nld?7 5 7 FARM TANK-YES❑ NO 0 I. TANK DESCRIPTION FOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDK B. MANUFACTURED BY: �y C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ��S! 11. TANK CdNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),13 NOT MARKED,COMPLETE ITEM D. CTI A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMR. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL F-]3 CHEMICAL PRODUCT F] 4 OIL 1 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.K C.A.S.K: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD WIFIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL E-15 CONCRETE E]6 POLYVINYLCHLORIDE F-17 ALUMINUM El IDA METHANOL COMPATIBLE FRP �❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑N OTHER ❑ 1 RUBBERLINED ❑2 ALKYDUNING ❑3 EPDXYLINING ❑4 PHENOUCUNING C.`IIININRGIOR ❑S GLASSUNING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑ NO ❑99 OTHER 0.CORROSION ❑ I POLYERILENEWRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE 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 B.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 A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U S 1OD%METHANOL COMPATIBLE FRP 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. P S 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 6 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED E SIGNATURE) DATE If LOCAL AGENCY USE ONLY COUNTY K JURISDICTION M AGENCY K FACILITY ID K TANK ID K o / IT5M no CURRENT LOCAL AGENCY FACILITY ID 0 {{ APPROVED BY NAME PHONE E WITH AREA CODE rv7 I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE Q 1 J CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: YJ FORMS(62988) THIS FORM MUST BE ACCOMP A FACILITY/SITE APPLICATION, FORM 'A',UNLE URRENT FORMA' HAS BEEN FILED y✓L DATA PROCESSING COPY