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STATE OF CALIFORWA WATER RESOURCE$,CONOL BOARD •`' � <br /> FORM 'S'. UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATIONS °' <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> 1'--I i o <br /> MARK ONLY LJ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANG€OF INFORMATION 7 PERMANENTLY CLOSED TALK <br /> ONE ITEM 2 INTERIM PERMIT4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED <br /> FACILITY/SITE NAME WHEREMANK IS INSTALLED: L ,� `� L".1 L FARM TANK-YES❑ NO (, <br /> C71 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY <br /> A. OWNERS TANK ID q , y' EI. MANUFACTURED BY: Gf cy) <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 111C2 6)0 <br /> II. TANK C TENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. Ej(MOTOR VEHICLE FUEL 2 PETROLEUM B. C Q I UNLEADED LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT © 4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS E] 80 EMPTY [:]95 UNKNOWN ❑ 2 WASTE 7 METHANOL 99 OTHER{DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.N. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOLI A,B,C,&D <br /> X TYPE OF ® 1 WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> j SYSTEM 2 SI WALLED 4 SECONDARY CONTAINMENT ® 99 OTHER <br /> I STEEL/IRON ❑2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WIfISERGLASSREINFORCED PLASTIC <br /> B.TANK [—]5 CONCRETE 5 POLYVINYLCHLORIDE 7 ALUMINUM 6 100%METHANOL COMPATIBLE FRP <br /> • , MATERIAL <br /> ©9 BRGNZE E] 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR I RUBBER LINED 2 ALKYO UNiNG 3 EPDXY LINING 4 P UC LINING <br /> LINING ❑ 5 GLASS LINING ❑6 UNUNED 95 UNKNOWN <br /> El IS LINING MATERIAL COMPATIBLE WITH 1 W%METHAIIOL? YES NO 99 OTHER <br /> D. CORROSION ❑ t POLYETHLENEWRAP AR OR <br /> ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> -, PROTECTION F1 5 CATHOOK:PAOTECTION B/91'NO'NE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF AE9 E GROUND, U 1F UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U_- SUCTION A fqj PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> i <br /> B.CONSTRUCTION A U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> U STEEL RON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P $ 9 VISUAL CHECK 6 2 1 NCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATEODATE LAST USED IMO/MRI 2. <br /> ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? YES NO <br /> [i{�LLOHS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT. <br /> APPLICANT'S NAME IPRINTEO 6 SIGNATURE) DATE <br /> LOCAL A ENCY USE ONLY <br /> COUNTY F JURISDICTION Y AGENCY It FACILITY ID 0 TANK 10 it <br /> CURRENT LOCAL AGENCY FACILITY IO 11 APPROVED BY NAME PHONE Ii WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> zf <br /> CHECK S PERMIT AMOUNT RCHARGE AMT. FEE CODE 1411PT II BY: <br /> FORM B(6.29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA` NAS BEEN FILED <br /> [] T <br />