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STATE OF'CALIFORNIA* WATER RESOURCESCONTRO&ARD FORM 'S'. UNDERGROUND STORAGE TANK PROGRAM .TANK ' Z-. TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z :U MARK ONLY '--❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OFINFOHMATION ❑ 7 PERMANENTLY(�OSED TANK ONE ITEM .^-'.❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE( FACILITY/SITE NAME WHERE TANK 18 INSTALLED: =i '; �"7i i ✓, f C.L) j�(/ ": / ,FARM TANK-YES ! NO ❑ N 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY =i > CD A OWNERS TANK ID N B. MANUFACTURED BY: C.YEAR INSTALLED (.�/` 0. TANK CAPACITY IN GALLONS: �� 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED CrI71ESEL ❑ 3 CHEMICAL PRODUCT ❑1 OIL E I PRODUCT ❑1 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS C] 5 HAZARDOUS El 80 EMPTY El 95 UNKNOWN ❑2 WASTE ❑7 METHANOL E]99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N CA S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLYIN BOX A,B,C,E D A TYPE OF ❑ I DOUBlEWAL ED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑I SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUODN ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑N STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 COIICRLTE ❑6 POLYVWYLCILOHIDE ❑ 7 ALUMINUM ❑8 10091 METHANOL COMPATIBLE FRP MATERIAL. 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑.1 RIIBBFALNAD ❑2 X MUNING ❑3 EPDXYLNING ❑1 PHENOLICUWNG LINING ❑5 GLASSL'" ❑6 UNLINED ❑95 UNKNOWN ❑ISUINWOMATBNALCOMPATIBUWITM100%MET Wa? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYMILEHEWRAP ❑2 TAR OR ASPH&T ❑3 VIVA WRAP ❑1 FIBERGLIM REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UWNDWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 6 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 E / VISUAL CHECK P S 2 INVENTORY RECONCILLATION P B 3 VADOSE WELLS P B I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S S PRECISION TESTING P 2 7 PRESSURETESTING 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 W GALLONS INERT MATERIAL? ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID Y TANK ID N CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME - C PHONE/WITH AREA CODE i"LI � S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE c . ,9- CHECK) WRMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPTN BY:, Ph, FORMB(9.29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HASBEENFILED