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17-7777wr 77, STATE OF CALIFORNlib WATER RESOURCES CONTR9 PROGRAM FORM 'S': UNDEWGROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN94NFORMATION FOR EACH TANK. MARK ONLY F-] 1 NEW PERMIT F-] 3 RENEWAL PERMIT [� 5 CHANGE OF INFORMATION El 7 PERMANENTLY CLOSED TANK ONE ITEM El 2 INTERIM PERMIT El 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE [:]8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# i ;,-q 3 -4- B. MANUFACTURED BY: V(v Mow 0 C. YEAR INSTALLED A lLdLyz2&f D. TANK CAPACITY IN GALLONS: I,Z&V &--( II. TANK CONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. F-] 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. F-1 1 UNLEADED 0 2 LEADED ❑ 3 DIESEL F-] 3 CHEMICAL PRODUCT F-] 4 OIL Ea'l"PRODUCT ❑ 4 GASAHOL D 5 JET FUEL ❑ 6 AVIATION GAS 1:1 5 HAZARDOUS [:] 80 EMPTY ❑r95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL 0 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,8,C,&D A.TYPE OF F-1 I DOUBLE WALLED F-]3 SINGLE WALLED WITH EXTERIOR LINER []�r%UNKNOWN SYSTEM F--] 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER Ez'l'STEEL/IRON F--] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE MATERIAL F-1 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP [:] 9 BRONZE [:] 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR F-1 1 RUBBER LINED El 2 ALKYD LINING F--] 3 EPDXY LINING E] 4 PHENOLIC LINING LINING F-] 5 GLASS LINING F-]6 UNLINED ❑�95 UNKNOWN [:] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [:] NO 0 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT F-] 3 NYL WRAP F-1 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN El 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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<g 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE AU UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A-Qr)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 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 BE CIRCLED. P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING a S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMA DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH PoIX -(-p Iq SUBSTANCE REMAINING IN GALLONS INER MATERIAL? YES 0"I'llwaJI&I . r�Meee0r'� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# = I I I I EI I I LoLo I � 13� 1 o' l -; I I T--FD— CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE P6z-[) -&L) PERMIT NUMBER I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHIECK# PERMIT AMOUNT &RCHARGE AMT. FEE CODE IPT# BY: FORM B 6-2?28� THIS FORM MUST BE ACIMANIED BY A FACILITY/SITE APPLICATION, FORM W*UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY