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STATE OF CALIFORN10 WATER RESOURCES CONTRdWARD FORM 'S': i UNDERGROUND STORAGE TANK PROGRAM TANK =- TANK PERMIT APPLICATION INFORMATION 6nH COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. l a MARK ONLY -❑ I NEW PERMIT ❑3 RENEWAL PERMIT �' 5 CHANGE OF INFORMATION 7 PERMANENTLYCLLUFIK zCD ONE ITEM 2 INTERIM PERMFT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVEa � / / CD FACILITY/SITE NAME WHERE TANK IS INSTALLED: /�><, / < N/>N-17 /,� (Aj i?/�� VP/� ILTTf ° FARM TANK-YES❑ NO N G TANK DESCRIPTION COMPLETE ALL ITEMS•IFUNKNOWN—808PECIPY },� O A. OWNERS TANK ID N B. MANUFACTUflED BY: �� (� C. YEAR INSTALLED i ?. D. TANK CAPACITY IN GALLONS: �JLj Gj If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. E] 1 UNLEADED 2 LEADED 3 DIESEL ❑3 CHEMICAL Pfl000LT E]1 OIL I PRODUCT ❑1 GASAHOL 5 JET FUEL 6 AVIATION GAS ❑5US ❑BO 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 B CA.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.i D A TYPE OF - ❑ 1 DOUBLE WNtID ❑3 SINGLE WALED MTH EI(TEROR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑1 SECONDARYCONTAINMENT ❑ 99 OTHER B.TANK ' ❑I STEEUTAON ❑2 STAINLESS STEEL ❑3 FIBUIGIASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL. ❑5 CONCRETE E]6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP : ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 BNKNOWN ❑99 OTHER C.INTERIOR ❑ I RBBEAUNED ❑2 AlAYO UNUNO 3 EPDXY UMNG ❑ 1 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ISUNING MATERIAL COMPATIBLE MTH 1001E MErHAN1L7 ❑YES ❑NO ❑99 OTHER D.CORROSION ❑1 PMYEREENEWRAP ❑2 TAR ORASPtMLT ❑3 VINYL WRAP ❑1 FIBERGLASS AEINFORCEOPLASiIC 'In• .. PROTECTION -❑5 CATHODIC PROTECTION ❑91 NONE ❑P5 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE I Ec EIAL !!! TION A U 2 PRESSURE A U 7 GRAVITYA U 91 NONE A U 95 UNKNOWN AU 99OTHERLE WALLED A U2DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U99OTHER EL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPEA U 91 NONE MINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRPVANIZEDSTEEL A U 95 UNKNOWN A U 8100%METHANOL COMPATIBLE FRP A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORS FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P t I VISUAL CHECK P i t INVENTORY RECONCILIATION P t 3 VADOSE WELLS ECISION TESTING P ► i 1 ELECTRONIC MONITOR P t s GgOUND WATER MONITORING WELLS P t 8 PRi z PRESSURE TESTING P i 91 NONE P 5 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3.WAS TANK FILLED WITH 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID Y TANK ID N / y,. CURRENT LOCK AGENCY FACILITY ID N APPROVED BY NATE PHONE 1 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EKPIRATION DATE CHECK PERMIT AMOUNT IV AMT. FEE CODE EIPTN BY: �,,� FORM110-29-0) THIS FORM MUST BE ACCOMPANIED BY A FACILITYJSITE APPLICATION, FORM 'A',UNLESS A CURRENT FORuv uec occ��„�/ ✓/2