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STATE OF CALIFORNIA WATER RESOURCES CONTKOL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING_!WORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ D RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 703? FACILITY/BITE NAME WHERE TANK IS INSTALLED: �/5 3 k h -le h'ff c'�, FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: ale__ C. YEAR INSTALLED (.f�� D. TANK CAPACITY IN GALLONS: U p II. TANK TENTS IF(A.9),IS MARKED,COMPLETE ITEM C.IF(A.T),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE NEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED E] 0 DIESEL ❑ O CHEMICAL PRODUCT ❑ 1 OIL 1 PRODUCT ❑ A GASAHOL ❑ 5 JET FUEL ❑ 6 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 A CA.S.E GA.&N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D A TYPE OF ❑ 1 PIECEWALLED 7 SINGLE WALLED WITH EGERIOR LINER 09 UNKNOWN SYSTEM Z 9 WALLED ❑ /SEOGNOAfNCONTMNMENT ❑ 99 OTHER I STEE/IRON ❑2 STAINLESS STEEL ❑ 9 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ MATERIAL 5 CONCRETE ❑E POLYVINYL CIEDRDE ❑ I ALUMINUM ❑ B INA METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN 99 OTHER ❑ I RUBBERUNID ❑ 2 LINING ❑ B EPOAYLINING ❑I PHENOLGUNING G INTERIOR LINING ❑ 5 GLASS UMfG 6 UMJNEO ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETLEENE WRAP ❑ 2!3ASPHALT ❑ 9 VINYL WRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION - I NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A V UCTION A U 2 PRESSURE A U 0 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U S LINED TRENCH A U 91 NONE A U UNKNOW A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGIASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL CLAD W/FRP A U 8 1009E METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL AGNKNG 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 t IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 0 SE WELLS P t A ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P t 8 PRECISION TESTING P % 7 PRESSURE TESTING 91 NONE2 P S 95 UNKNOWN P t 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESiIMAIED DATE UST USED(MO/YR) TuTIMATEOOUANTHYOF O.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATEHIAL7 ❑ YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED S SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY fJURI��SDICTII{I0ON Y AGENCY S FACILITY ID N TANK ID N ITT CURRENT LOCAL AGENCY FACILFTY ID F APPROVED BY NAME PHONE IT WITH AREA CODE CA/,aLGJE i _ PERMITHUMMIR PERMIT APPROVALDAT! PERMIT EXPIRATION DATE 1 CHECKS PERMIT AMOUNT - SURCHARGE AMT. FEE CODE RECEIPT F BY: "'v {0114 R Ie-29-SSl THIS FORM MUST RF ACCDMPANIFD R•A FAru Ir Ie mTr Ana Ir mnu cnou w• uw eee............. ....... .. ...._-......__