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STATE OF CALIFOSIA WATER RESOURCES CAROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAMQO TANK > • TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 NEW PERMIT ❑A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED P FACILITY/SITE NAME WHERE TANK 181NSTALLED: l Q3 O , /'<� FARM TANK-YES NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK IDN 8. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL E]2 PETROLEUM B. C. ❑ I UNLEADED L]2 LEADED ❑3 DIESEL ❑ 3 CHEMICALPRODUCT ❑ A OIL I PRODUCT ❑ A GASAHOL ❑5 JET FUEL ❑B 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 C.A.S.N C.A.S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,8 D A.TYPE OF ❑ 1 Wim ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM BNOLEWAA ❑1 SECONDARY CONTAINMENT ❑99 OTHER B.TANK ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑7 FIBEfgU$S ❑I STEEL CUD W/FIBERGLASS REINFORCEDPLASTIC MATERIAL ❑5 CITE ❑0 POLYVINYL CLOIIDE ❑ 7 ALUMINUM ❑B IOD%METHANOL COMPATIBLEFRP ❑9 BRONZE ❑ TO GALVANIZED STEELUNKNOWN ❑ 99 OTHER ❑ I ❑3 EPDXY LINING C.INTERIOR [:] I RIBBEAUNED 2 ALKYD LINING ❑I PHENIX1CunINO LINING ❑5 GUIMUNING ❑N UNLINED ©-9 NKNOWN ❑S LINING MATERIAL COMPATIBLE WITH ION,METHANOL? E]YES [j No E] 99 OTHER FD.CORROSION ❑ I POLYEREENEWRAP ❑2 TAR OR ASPHALT [:] 3 VI WARP ❑1 FIBERGLASS REINFORCED PLASTIC MIOTECRON ❑ 5 CATHODIC PROTECTION ❑91 NDNE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U BI NONE A U 9 NKNOW A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U-95 LINK OW A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U BCONCRETE A U 7STEEL CLADW/FRP A U B L00%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U KNOW 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 1VI5 JAL CHECK P B 2 INVENTORY RECONCILIATION P B 3VADOSE WELLS P B K ELECTRONIC MONITOR P t 5 GROUND WATER MONITORING WELLS P N N PRECISION TESTING P B 7 PRESSURE TESTING P N 91 NONE P N 95 UNKNOWN P N 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATEDDATELASTUSED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WASTANKFILLEDWITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO GALLONt THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JUR�ISDICTITON�N AGENCY N FACILITY ID N JAREACODE C� c� y C� 13 141 CURRENT LOCAL AGENCY FACILITY ID/ APPROVED IT NAM! PHPERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DAT! CHECKN PERMIT AMOUNT SURCHARGE AYY. FEECOD! BIG