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STATE OF CALIFORNI WATER RESOURCES CONTR*OARD UNDERGROUND STORAGE TANK PROGRAM tem `e FORM 'S" TANK PERMIT APPLICATION INFORMATION U Z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑B TANK REMOVED 1J MARK ONLY ❑ q AMENDED PERM IT ❑6 TEMPORARY TANK CLOSURE W ONE ITEM ❑ 2 INTERIM PERMIT FARM TANK-YES❑ NO w FACILITY/SITE NAME WHERE TANK IS INSTALLED: 'Jv 05��/ 1. mC. YEARlNST77E77:5En ITEMS-IF UNKNOWN-SO SPECIFY PE MANUFACTURED BY: L YlW Ngo[) D. TANK CAPACITY IN GALLONS: 11. TANK ONTENTS IF(A.7),IS MARKED,COMPLETE ITEM C.IF(A.7),IS NOT MARKED,1 UNLEADED MPLETE IT❑ 2 LEADED ❑ 3 DIESEL B 6 AVIATION GAS A, 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL LL-/3�� 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS.If HAZARDOUS SUBSTANCE STORED&GAS.X III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑ 95 UNKNOWN rTYPE K�2SINGLIE EWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 99 OTHER WALLED ❑4 SECONDARY CONTAINMENT ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CIAOWIFIBERGUSSREINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑7 LUMINUM ❑B 100%METHANOL COMPATIBLE FAP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL 95 UNKNOWN ❑ 99 OTHER ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ HENOLIC LINING ❑ I RUBBER LINED IV 95 UNKNOWN C.INTERIOR ❑ 5 GLASS LINING ❑6 UNLINED LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 yyVYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION F-1 5 CATHODIC PROTECTION ❑91 NONE 9595 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE ONE A U 95 UNKNowN A U 99 OTHER A SYSTEM TYPE A u 1 sucrloN A PRESSURE A U 3 GRAVITY B. CONSTRUCTION p U 1 SINGLE WALLED A U 2 DOUBLE WALLED p U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHLH A U t STEEL/IRON A U 2 STAINLESS STEEL A U T STEELC CLALD W/OFRP E(PVC) A U 8100%METHANOL COMPATIBLE FRP 91 NE C.MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 99 OTHER A U 9 GALVANIZED STEEL A 95 UNKNOWN V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p g 95 UNKNOWN P S 99 OTHER- P S I VISUAL CHECK S 2 INVENTORY RECONCILIATION P g 3 VNADOONEE WELLS P S 4 ELECTRONIC MONITOR P s 5 GROUND WATER MONITORING WELL 6 PRECISION TESTING P S 7 PRESSURE TESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE s WAS TANK FILLED WITH 2. ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑ NO 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS 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) LOCAL AGENCY USE ONLY TANK ID k COUNTY k JURISD�� AGENCY k FACILITY ID# [IIIAPPROVED BY NAME PHONE k WITH AREA CODE CURRENT LOCAL AGENCY FACILITY ID X cqT 1`7 PERMIT APPROVAL DATE PER T EX IRA ION DATE PERMIT NUMBER SURCHARGE AMT. FEE CODE RECEIPT k BY: CHECKX PERMIT AMOUNT _..,._....0 ui,cT nP ArenuoaNlE FACILITYISITE APPLICATION, FORM 'A',UNLESS A C r ENT FORMA' HAS BEEN FILED