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STATE OF CALIFORNI& WATER RESOURCES CONTR OARD FORM 'S': UNDERGROUND STORAGE TANK PR AMS n: TANK TANK PERMIT APPLICATION INFORMATION m COMPLETE A SEPARATE FORM WITH THE FOLLOWINgANFORMATION FOR EACH TANK. _ 10 MARK ONLY F-] I NEW PERMIT [—]3 RENEWAL PERMIT T5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 35,15C. FARM TANK-VES❑ NO d►h 1-a 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 4�b A. OWNERS TANK ID - B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 40 .� II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 GASAHOL n 5 J¢FUEL ❑6 AVIATION GAS .1 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 1^moi 99/OTHER(DESCRIBE IN ITEM D,BELOW()' D. IF NOT MOTOR HAZAARDOUS SUB CLE TIANCE STORED 8 CA.S.#FUEL,ENTER NAME OF /�S ha- ft C.A.S.#: e0501-T0'- 7 III. TANK CONSTRUCTION MARK ONE ITEM ONLY I BOX A B,C,8 D A.TYPE OF ❑ I DGUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM [�2 SINGLE WALLED ❑4 SECONDARYCOMAINMEM ❑ 99 OTHER ❑ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑fi POLYVINlLCHLOPoGE ❑ 7 ALUMINUM ❑B IDD%METHANOL COMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER ❑ 1 RUBBERUNED ❑ 2 ALKYD LINING ❑3 EPDXY UNING ❑4 HE14OLIC UNING C. INTERIOR LINING ❑5 GLASS LINING ❑ 6 UNUNED UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 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 U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 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 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 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 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 �I Q GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. Y APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# DD © OD CURRENT LOCAL AGENCY FACILI ID&_ APP�VED BY NAME �� PHONE#WITH AREA CODE , S � PERMIT NUMBER PERMIT APPROVAL DATE PERIAI EXPIRATION DATE CHECK# PERMITAMOUNTSURCHARGE AMT. FEE CODE IiiRECEIPT# BY: FORMB(6-29-83) THIS FORM MUST BE ACCOMPANIED AFACILITYNITE APPLICATION, FORM 'A',UNLESS A"FARENT FORMA' HASBEENFILED DATA PROCESSING COPY