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STATE OF CALIFORNIA4 WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM INFORMATION ry -o TANK TANK PERMIT APPLICATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION E:l 7 PERMANENTLY CLOSED))NK ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 10 8 TANK REMOVED moil N FARM TANK-YES L] NO FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3S'S j c( A S Oc IJ w Q 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY co A. OWNERS TANK ID# I non 1:-o, B. MANUFACTURED BY: (,(,,,kA/ou od C. YEAR INSTALLED jqqj D. TANK CAPACITY IN GALLONS: S I S II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. [M 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 0 2 LEADED [X3 DIESEL E] 3 CHEMICAL PRODUCT ❑ 4 OIL ® 1 PRODUCT 4 GASAHOL E] 5 JET FUEL 0 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL [:]99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.A' HAZARDOUS SUBSTANCE STORED 8 C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,At D A.TYPE OF ❑ 1 DOUBLE WALLED F-] 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM F-] 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT E199 OTHER 1 STEELPRON F-1 2 STAINLESS STEEL 0 3 FIBERGLASS F-] 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE F-] 6 POLYVINYLCHLORIDE 0 7 ALUMINUM F1 8100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL ©95 UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING F-] 4 PHENOLIC LINING C. INTERIOR LINING F-] 5 GLASS LINING F-16 UNLINED 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES F-] NO F_� 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP F-] 2 TAO ORASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION Ej 5 CATHODIC PROTECTION E] 91 NONE ER.95 UNKNOWN Ej 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 401 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 (GSA NKNOW 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 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UO UNKNOW 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 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING IDS 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? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY* JURISDICTION# ;/-AGENCY# FACILITY ID# TANK ID tp l LJ� I—L—J-1 G o Is 6 0 0 1 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE I-c C 0 2 8 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATIO DATE CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTS BY: / SSSSIS FORM B(6-29-sa) THIS FORM MUST BE ACCOMPAN19M A FACILITY/SRE APPLICATION, FORM 'A',UNLE ACENT FORM•A' HAS BEEN FILED i DATA PROCESSING COPY