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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION ; COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ __ Z IO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ®B TANK REMOVED 0 ?1 rlo FACILITY/SITE NAME WHERE TANK IS INSTALLED: loq S• C (FQ Rp(/1i FARM TANK-YES❑ NO Sl I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: LJAQ N C. YEAR INSTALLED IICjsJA9WAd D. TANK CAPACITY IN GALLONS: /®4D Q at II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),I NOT MARKED,COMPLETE ITEM D. A. Xj 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑60 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&CA.S.N -- - C.A.S.4 Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALED ❑4 SECONDARY CONTAINMENT ❑99 OTHER Q 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYWNYL CHLORIDE ❑7 ALUMINUM ❑B IW%MEMNOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ IO GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER it C. INTERIOR ❑ 1 RUBBER LINED El2 ALKYD LINING F-13 EPDXY LINING E:] 4 PHENOLIC UNING LINING ❑5 GLASS LINING ®6 UNUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ i POLYETHIENE WRAP ❑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 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©1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 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 IP SUBSTANCE REMAINING IN pAA&.WIYM INERT MATERIAL? ❑YES [RN Y GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S=SIGNATURE) DATE ', LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY ID N TANK ID M 3 9 3 a 3 I I I / o 3 i c? i CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE rn L n) 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHI PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORMB(6-29.66) THIS FORM MUST BE ACCOMPANIEf sdFACLLITY/BRE APPLICATION, FORM 'N,UNLESS CMENT FORMA' HASBEENFILED ��L DATA PROCESSING COPY