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STATE OF CALIFORNIft WATER RESOURCES CONTRO ARD Qo FORM 'S': UNDE ROUND STORAGE TANK PROMAMTANKTANK PERMIT APPLICATION INFORMATIONCOMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑.#TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: ��j� brl C Q (5 FARM TANK-YES❑ No Q- ,� CCl 1. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID q ��Z}�� I a .� B. MANUFACTURED BY: k 1 ' l\kK7CW. C. YEAR INSTALLED Kn knob r, D. TANK CAPACITY IN GALLONS: r CJ� Cl[Yv�ID 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A, MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. [:] I UNLEADED [ LEADED ❑ 3 DIESEL ❑ 3 CHEMICALPRODUCT ❑ 4 OIL ❑'f PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM U BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.H C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM [ t SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER B.TANK STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑9 BRONZE ❑ E] 7 ALUMINUM 95 UNKNOWN ❑B 100%METHANOL COMPATIBLE FRP 10 GALVANIZED STEEL [:] ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑q PHENOLIC LINING LINING ❑5 GLASS LINING E3rUNUNED 95 UNKNOWN I r/ ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? El YES E] NO �99 OTHER V R D. CORROSION ❑ 1 POLYETHLENE WRAP ❑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 IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A USUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 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 A 95 UNKNOWN A U 99 OTHER A U I 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 U 5 ALUMINUM A U 6 A U 7 STEEL CLAD W/FRP A U 8100%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 IVISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3V EWELLS P S I ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# 3 TANKID# ooaa � 3 o a CURRENT LOCAL A NCy FAf,l;p l 9 APPROVED BY NAME UY l)ft..J\ V I a � t /� /� I , 1 PERMIT EXPIRATION DATE IT AMOUNT SURCHARGE AMT. FEE CODE PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE 0 �/IliTE 1\ \ CHECK N PERM RECEIPT BY: FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIOTYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HASBEENFILED DATA PROCESSING COPY