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STATE OF CALIFORNI!- WATER RESOURCES CONTROL PARD FORM 'S': UNDERGROUND STORAGE TANK PROa%AM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �o� ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7<j Y/(24 L{ FARM TANK-YES❑ NO 4b, 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY G w A. OWNERS TANK ID# B. MANUFACTURED BY'. C. YEAR INSTALLED S GI D. TANK CAPACITY IN GALLONS: /4� w o II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. /L 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B TEGA DED ❑ 2 LEADED [ZJDIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT OL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPN ❑ 95 UNKNOWN ❑ 2 WASTE ANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /�� C.A.S.#: HAZARDOUS SUBSTANCE STORED 8 CA S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,B D A TYPE OF ❑ 1 DW EWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WA ED ❑4 SECONDARY CONTAINMENT ❑99 OTHER iEEUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER UNED ❑2 ALKYD NING ❑ 3 EPDXY LINING F-] 4 PHENOLIC LINING C.INTERIOR ❑LINING ❑ 5 GLASS LINING NUNED ❑ 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100W METHANOL] ❑YES F] NO [5j,$59'OTMEP D.CORROSION ❑ 1 POLYETHLENEWRAP AR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION k U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALLED A, U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A: U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM AlU CONCRETE A U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A' UNKNOWN A U 99 OTHER IV V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED( O/YR) 2. ESTIMATED QUANTITY OF 3, WAS TANK FILLED WITH ,`., GALLONS A SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION M AGENCY# FACILITY ID R TANK ID# m CURRENT LOCAL AGENCY FACILITY IOM APPROVED BY NAPE PHONE N WITH AREA CODE 3 06 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT UPIRATIONbXTE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: 1 FORMS(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A ENT FORM'R HAS BEEN FILED / lll/ii DATA PROCESSING COPY ./