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F.*Fr. . STATE OF CALIFOR WATER RESOURCES CONT OARD FORM 'S': UNDERGROUND STORAGE TANK PROTLRAM o hm TANK TANK PERMIT APPLICATION I FORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING TION FOR EACH TANK. C MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMAT 7 PERMANENTLY CLOSED TANK (� ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMP RYTANK CLOSURE ❑8 TANK REMOVED �(J FACILITY/SITE NAME WHERE TANK IS INSTALLED: FAIRGROUNDS INDUSTRIAL PARK FARMTANK-YES❑ NOCD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Fs A. OWNERS TANK ID# UNKNOWN B. MANUFACTURED BY: UNKNOWN C. YEAR INSTALLED UNKNOWN D. TANK CAPACITY IN GALLONS: 2500 U. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ® 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ® 1PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS E]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&C.A.S.# C.A.S.#: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ®95 UNKNOWN Im- SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARYCONTAINMENT ❑99 OTHER Z �_ ❑ 1 STEELPRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLA B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP R3 MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ®95 UNKNOWN ❑99 OTHER _ I" ❑1 RUBBERLINED ❑2 ALXYDUNING ❑ 3 EPDXY LINING ❑4 PHENOUCUNING C. INTERIOR mm Cal LINING ❑5 GLASSUNING ❑ 6 UNLINED © 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1 DO%METHANOL? ❑YES ❑ NO E]99 OTHER yD D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE © 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A FABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1.SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A&95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 095 UNKNOWN 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 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING P 8 91 NONE 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOYYR) 2EESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH UNKNOWN I SUBSTANCE REMAINING IN O GALLONS INERT MATERIAL? E]YES ® NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPL ANTS NAME(PRI EDBSIGNATURE) GATE SYDNEY LEVIN LOCALAGENC US ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# -3 g O G 1 p 1 / CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA COPE A ,E' rod� PERMIT NUMBER PERMITAPPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY6/3 FORM B(6-29-69) THIS FORM MUST BE ACCOMPANIER Y A FACI , /SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY