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STATE OF CALIFOR& WATER RESOURCES CONDI BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM Oi.-- TANKMARK TANK PERMIT APPLICATION INFORMATIONCOMPLttE A 9EpAf1AtE FORM WITH tHE FOLLOWING INFORMATION FOR EACH TANK.O ❑I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 NE 1t ❑2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ❑R TANK REMOVED [FA;ClLI"/l:y"AMlITE WHERE TANK I!INSTALLED: _ ; 5 , ,�� F s ;f"�l FARM TANK-Y S❑ NO L' I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY t A. OWNERS TANK IDR B. MANUFACTURED BY: L C. YEAR INSTALLED "/ _ D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.11 ,IS MARKED,COMPLETE ITEM C.IF(A.%IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. - C. ❑ 1 UNLEADED U 2 LEADER ❑ 3 DIESEL ❑S CHEMICAL PRODUCT 4 OE ❑ I P UCT ❑ A GASAHOL ❑5 JET FUEL ❑R AVIATION GAS OU ❑ 5 HAIARDS ❑AO EMPTY ❑95 UNKNOWN v 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM 0,BELOW( D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAB.II C A.S.9: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,B,C,A D A TYPE(W ❑I WALLED ❑3 SINOLE WALLED WITH EXTERIOR LINER ❑95 twN01VN SYSTEM 2 WAILED ❑A SECONDARY CONTAINMENT ❑99 OTHER --- I STEEURON ❑2 STAINLESS STEEL [:]9 FIBERGLASS ❑ L STEEL GAD W/FIBERGLASS REINFORCED PLASTIC 1.TANK ❑ MATERIAL 5 CONCRETE ❑0 PGLYVIWL CHLORIDE ❑ 7 ALUMINUM ❑A IOD%METINNG COMPATIBLE FRP ❑9 MR: ❑ 10 GALVANIZED STEEL ❑95 UA WM ❑99 OTHER C. INIERIOp ❑ t RRBERLR 0 ❑2 LINING ❑ 3 EPDXY LNDIO ❑ 1 PHENOUCLIMNO LRRNO ❑5 IRA99tw 5 UNLINED ❑95 UNKNOWN ❑B LINM MATERIAL COMPATGLE WITH 100%MpHANoL7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 PGYERAENE WRAP ❑2 T ASPHALT ❑3 VINYL WRAP ❑ 1 RBERGLAss REINFORCEDPUsRc PROTECTION ❑5 CAPROM PRO1ECTgN L319INONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLEAIFABOVE GROUND. UIFUNDERGROUND.BOTH IFAPPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 OFIAVITV A U 91 NONE A U N A U 99 O11fER 1.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 9 'GNKNT)WN- A U 99 OTHER EFL/I A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / FIBEROLASS PIPE A U 91 NONE G MATERIAL A U S klLUM—fNUM A U R CONCRETE A U 7 STEEL CUD W/FRP A U B IOD%METHANOL COMPATIBLE FnP A U 9 OALVANIIEO STEFL 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. 9 IVMUALcHecx P 1 2NNEN70MRECONCILIATION P 1 3VADOSEWELLS P 9 AELECTRONICMONITOn P 9 50ROUNDWATERMONITOnINOWFLLS P S 9 PRECISIONTESTINO P 1 T PRESSLR t tESTINO =91 NONE P 1 95 UNKNOWN P 9 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.tu'M IED DATE LAST USED(MOND) 2. ESTIMATEDOUANTITYOF 3, WAS TANK FILLED WITH F� SUBSTANCE REMAINING IN 17ALLON9 INERT MATERIAL? ❑ LI YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND GOf7REC T. APPIJCANT'S NAL1E(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION � AGENCY S FACILITY IDA_ TANK ID 9 CURRENT LOCAL AGENCY FACILITY 101 APPROVED BY NAME PHONE A WITH AREA CODE 71P1S � - -,-- PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CRECKF PERMIT AMOUNT 9URCHAROE AMT. FEE CODEECEIPTA eY; TOM R le"29" THIS FORM WAt 1E ACCOMPARRA BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS SEEN FILED Jun_nnnv