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STATE OF CALIFORNWATER RESOURCES CONTR BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM a ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ',.o O ONE ITEM ❑ I—I8 TANK REMO LY CA6D6E8R�ryK ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVEL_(/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: b /. V6.L/ FARM TANK-YES NO ❑ N I. TANKDEcyl SCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-'SOSPECIFY r(rny A. OWNERS TANK ID R B. MANUFACTURED BY: W C.VEAp INSTALLED D. TANK CAPACITY IN GALLONS O DWWWD II. TANKCONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 'DIESEL ❑3 CHEMICAL PRODUCT ❑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 8 CA.S.R N'4 CA.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D 1 BLE WALLED ❑351NGLE WALLED WITH EXTERIOR LINER A TYPE OF ❑ ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S TANK AhRIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 'LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASSUNING 8 UNUNED ❑95NKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES [:] NO E'99 OTHER ��✓R'�/ D. CORROSION ❑ I POLYETHIEME WRAP ❑2 TARORASPHALT ❑3,VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTION ❑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 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 ALU- 5 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A A 6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. Pik)�+. 2L P 8 1 VISUAL CHECK P $ 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING rpw9l NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTI ATED DATE LAST USED(MOYYR) 2. ESTIMATED D ANTITY OF 3.WAS ANK FILLED WITH SUBSTA E pfRINING IN �1fi J{ATERIAL7 ❑YES ❑ NO V GALLONS /V 'L) I T IS 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 R JURISDICTION R AGENCY R FACILITY ID$ TANK ID R 1010 14 1= = 1 E97!TI— CURRENT LOCAL AGENCY FACILITY IDR APPgY NAME �^ PHONE WITH AREA CODE PERMIT NUMBERPERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKR PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT R BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/STYE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY