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STATE OF CALIFORNIA` WATER RESOURCES CONTROP 40ARD FORM 'S': UNDEWGROUND STORAGE TANK PROoAAM Y „= TANK / TANK PERMIT APPLICATION INFORMATION (/ Y 611ili tft A§E'PAIUTE FORM WITH THE FOLLOWING INFORMATION FOR EA6H tANR. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 1 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑I AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED /7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: I 12-7 \ g FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID R B. MANUFACTURED BY: V C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 6-0--d II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.It(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT F-14 OIL F-11 PRODUCT ❑ 1 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS [:]5 HAZARDOUS ❑00 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&C.A.S.K C.A.S.K: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C,S D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN ' SYSTEM ❑2 SINGLE WALLED ❑d SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STENUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP MATERIAL S❑9 BRONZE ❑ f0 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER F-11 RUBBER UNER ❑2 ALKYD LINING F-13 EPDXY LINING ❑ A PHENOLIC LINING C LINING INTERIOR ❑ 5 GLASS UNINB ❑S UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE PATH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENEWFAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC 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 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 95 UNKNOWN A U 99 OTHER A U I STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U I FISERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,ORB FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. O S I VISUAL CHECK P 6 2 INVENTORY RECONCILIATION 11 0 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 0 5 GROUND WATER MONITORING WELLS S B 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 GALLONSINERT 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&SIGNATURE) DATE t LOCAL AGENCY USE ONLY COUNTY K JURISDICTION• AGENCY K FACILITY 10 R TANK ID R 6 1 7 Z G a o 2 CURRENT LOCAL AGENCY FACILITY ID A APPROVED BY NAME PHONE P WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE n� CHECK 1 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT F BY: FORM B(6 29-59) THIS FORM MUST BE ACCOMPANIE A FACILITYISITE APPLICATION, FORM 'K,UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY