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• • STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK '" TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING I EACH RMATION FOR H Qp TANK. MARK ONLY ❑ I NEW PERMIT ❑ S RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2INTERIM PERMIT I AMENDEOPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /') FACILITY/SITE NAME WHERE TANK IB INSTALLED: ��f�- c:-- . ,5 c - �..e FARM TANK-YES❑ O -12 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A OWNERS TANK 101 / B. MANUFACTURED BY: / `- C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A F I MOTOR VEHICLE NEL 2 PETROLEUM B. C. ED] I UNLEADED 2 LEADED ❑ G DIESEL ❑ 0 CHEMICAL PRODUCT ❑1 OIL B. PRODUCT ❑ 1 GASAHOL ❑ 5 JET FUEL ❑ e 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 6 CA.S.1 C.A.S.1: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,S.C,L D A TYPE OF ❑ I WALLED F-17 SINGLE WILLED WITH EXTERIOR LINER Ej 95 m" SYSTEM 2 SINIRE WAI-LED ❑ 1 SECOIAAIW'CONTAINMENT ❑ 99 OTHER 11K, STEEUMON ❑2 STAINLESS STEEL ❑7 FIBERGLASS ❑/STEEL CUD W/FIBERGLASS REINFOPCED PLASTIC B.TANK ❑ S CONCRETE ❑6 POLYV NR.CHLORDE ❑ 1 ALUMINUM 1 100%METHANOL COMPATIBLE FRP MATERIALJ ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C INTERIOR F-1I RUBBER LINED ❑ 2 LINING ❑ 0 EPDXY LINING ❑ /PHENOLIC UNING LINING ❑5 CUSS LUNG 6 LEUNED ❑ 95 UNKIMN ❑ IS LINING MATERAL COMPATIBLE WITH 100%METFLla? ❑YES ❑ NO 099 OTHER D. CORROSION ❑ I POLYETNIMWWAP ❑2 T ASPHALT ❑7 VINYLWRAP ❑ N FIBERGLASS REINFOWED PLASTIC PROTECTION ❑ 5 CAMMCPROTECTION91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U" I S6CTION A U 2 PRESSURE A U O GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 2 B.CONSTRUCTION A U NOLE A U DOUBLE WALLED A U 9 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U EEL/IflON A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 MI.UMINU A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B II%IW METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 RE CIRCLED. P & I VISUAL CHECK P `ION P 1 9 VADOSE WELLS P 1 1 ELECTRONIC MONITOR P 1 5 GROUNDWATER MONITORING WELLS P - RECISION TESTI G P % 7 PRESSURE TESTING P 1 91 NONE ► 1 95 UNKNOWN P 1 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/Y'R) 2. ESTIMATEDOUANTIIY OF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F-1YES [] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNAI URE) DATE LOCAL AGENCY USE ONLY COUNTY P JURISDICTION 1 AGENCY L FACILITY ID P TANK ID N ry CURRENT LOCAL AGENCY FACILITY ID/ APPROVED 0Y MANE PHONE 1 WITH AREA CODE 17 PCRYIT NUYIfR PERMIT APPROVAL DATE PEPYIT EXPIRATION DATE V` b CHECK! PERMIT AMOUNT IURCHAROEAMT. FEF COOL RECEIPTI Rr:e'01 je/l