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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM • TANK PERMIT APPLICATION INFORMATION TANK "COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 9 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ©y FACILITY/BITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID p C7/ B. MANUFACTURED BY: (,(� C.YEAR INSTALLED L�YCr 0. TANK CAPACITY IN GALLONS: 5-42 QOa_,C 11. TANK C TENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL LEUM A2WAST C. ❑ 1 UNLEADED ❑ 2 LEADED ❑9 DIESEL G CHEMICAL PROWCT OIL T ❑A GASAHOL ❑ 5 JET FUEL ❑S AVIATION GAS 5 HAZARDOUS -BO EMEMPTY ❑95 UNKNOWN ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N C.A.S.N: 111. TANK CONSTRUCT!PN MARK ONE ITEM ONLY IN BOK A,B,C.A D A.TYPE OF ❑ 1 RUED ❑0 SINGLE WALLED WITH EXTERIOR UKR ❑95 UNKNOWN SYSTEM Z WAILED ❑1 SECONDARY CONTAINMENT ❑ 99 OTHER © I STEELARON ❑2 STAIMfSSSTEEL ❑7 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC R.TANK ❑5 CONCRETE ❑/POLYVIWLO(LpIpE ❑ 7 ALUMINUM ❑ I IWIl METIMNOLCOMPATIBLEMP MATERIAL Ej 9 BRONZE ❑ 10 GAIVAYZEO STEEL ❑95 UNKNOWN ❑99 OTHER C INTERIOR ❑ I RUBBER LIKED ❑!}IUhO LINING ❑7 EPDXY LINING ❑ 1 PHENOLICUNING LINING ❑5 GLASSUNNO ©S UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE MIN 100%METHANOL7 ❑YES NO E] 99 OTHER D. CORROSION ❑ I POIYETHLENE VAMP ❑2 TAR OR ASPHALT ❑ 3w RAP E]1 fIBE11GlA55 REINFOflCEO PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NOW 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A LA I SUCTION A U 2 PRESSURE Ar D G Wtt A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.C'ONSTRUC'TION A U SINGLE VWAVID A U 2 DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U L/IRON/ A U 2 STAINLESS STEEL A U 9 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 . A U 8 CONCRETE A U 7 STEEL CLAD W/FHP 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 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 IYISUAL CHECK P 8 21NVENTORYRECONCILIATION P 8 3VADOSEWELLS P B I ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8. 8 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE ► 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 9.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 0 AGENCY N FACILITY ID 8 TANK ID/ I � I % � oZ _ S (] EC� CURRENT LOCALAGENCYFACILITY ID/ APPROVED BY NAME PHONE I WITH AREA CODE \\1 PIRMR MUMIER PERMIT APPROVAL OAT! PERMIT EXPIRATION OAT! AWL 'T\ CHECK/ PERMITAYOUNTwe I SURCHARDIE AMT. FEE CODE RECEIPT/ vUUU [hnu N,11.9W-MI THIS FORM MUST BE ACCOMPANIED AT A FACO 111151YE pon lraTlnu CFT DI • 'A• um eea a rlmoem ensu•n u /