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STATE OF CALIFORNI WATER RESOURCESCONTROSARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM #91452C TANSY k TANK PERMIT APPLICATION INFORMATION `y ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING,INFORMATION FOR EACH TANK. v/\ 1 ERMIT ®3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CL*NO T J IM PERMIT -14 AMENDED PERMIT ❑8 TEMPORARY TANK CLOSURE ❑8 TANK REMOVEDa FACILITY/SITE NAME WHERE TANK IS INSTALLED: Bill Parks CI)CVTOn FARM TANK-YES❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A. OWNERS TANK IDN 37 WC5720C I B. MANUFACTURED BY: ------ C.YEAR INSTALLED 1969 1 D. TANK CAPACITY IN GALLONS: 10,000 gallons IL 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. X❑1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL X❑ 1 PRODUCT ❑0 GASAHOL ❑5 JET FUEL ❑6 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 A C.A.S.N C.A.S.N: 8006619 111. TANK CONSTRUCTION MARK ONE FYEY ONLY IN BOX A,B,C,i D A TYPE OF ❑ 1 DIXRIFWALLM ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ®2 SINGLE WALLED ❑A SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRON ©2 STAINLESS STEEL ❑3 FIBERGLASS ❑A STEEL CURD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 109%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ I RIBBER UNED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑d PHENOLIC LINING C.INTERIOR ❑5 GLASS LINING ®6 LNUNED ❑%UNKNOWN LINING ❑IS LINING MATERIAL COMPATIBLE WITH IO(AL METHANOL? ❑YES ❑NO ❑99 OTHER F SION ❑1 POLYEMENEWRAP ❑2 TAR ORASPHALT ❑3 VIWLWRAP ❑M RBERGLASSREINfORCEDPUSDC CTION 5CA7IGOG PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U M UNKNOWN A U 99 OTHER B.CONSTRUCTION 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON 2 STAINLESSSTEEL. A U 3POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 108%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 6 1 VISUAL CHECK 6 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P 6 d ELECTRONIC MONITOR P E S GROUND WATER MONITORING WELLS Ot 6 PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE P 6 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED IMO/YR) 2.ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [—]YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF ,AN O H BE MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE u o A5:-4 i LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FAC TTY ID N TANK ID N 3 2 o 76= d 1 o -- CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE N WITH AREA CODE c#'ekIg 33 1 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK F PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT F BY: FORME(&29-BB) THISFORMY'wK BY AFACBmAIIEA#SX'AIIOK FORM'A', AgB�MT FOO& IM{BEENFRED 1 OVA PROCESSING COPY 2 LOCAL AGlNC11 3 FIAT COPY