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T;7-7-_--,7 77"1 SATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWINYNIFORMATION FOR EACH TANK. MARK ONLY r-1 I NEW PERMIT ❑3 RENEWAL PERMIT df5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TAN ONE ITEM E-1 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 62-0 W, &/hof4-�rj.Sof 17k FARM TANK-YESE] NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY to A. OWNERS TANK ID N U B. MANUFACTURED BY: C. YEAR INSTALLED 19 -11 D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.11),IS MARKED,COMPLETE ITEM C.IF(A-11),IS NOT MARKED,POMPLETE ITEM D. (-n A. M I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM c UNLEADED 2 LEADED ❑3 DIESEL F-1 3 CHEMICAL PRODUCT ❑ 4 OIL 6/1PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS 1:1 5 HAZARDOUS 80 EMPTY 0 95 UNKNOWN ❑2 WASTE El 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.N: xill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ I BLE WALLED F-13 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM /2)31NGLE WALLED ❑4 SECONDARY CONTAINMENT ED99 OTHER *TANK aalli,STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS [:]4 STEEL CLAD W/ABERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM Ej 8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL Ej 95 UNKNOWN ❑99 OTHER C.INTERIOR F-1 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING �4,WENOUC UNI NG LINING F-1 5 GLASS LINING F-1 6 UNLINED %UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [::] NO ❑99 OTHER D.CORROSION F-1 I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION [:]5 CATHODIC PROTECTION E]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 JOUI 2 PRESSURE A U 3 GRAVITY A U 99 OTHER IL CONSTRUCTION A U I SINGLE WALLED A 15 2 DOUBLE WALLED A U 3 LINED TRENCH AAU 95 UNKNOWN' A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE()VC) A U 4 FIBERGLASS PIPE 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 �) 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 4=4 [' VISUAL CHECK up S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS �1S 8 PRECISION TESTING P 3 7 PRESSURE TESTING P 3 91 NONE P 3 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 I SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? F-1 YES F-1 NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TOTHEBEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENICY# FACILITY 10# TANK IID* F 1 6 1 n CURRENT LOCAL AGENCY FACILITY 10 0 APPROVED_MY NAME PHONE#WITH AREA CODE PERMIT UMBER PERMIT APPROVAL DATE -PERMIT EXPIRATION DATE le-W CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE -'.CEIPT# OY. FORM B(3-7-e8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SfTE APPLICATION, FORM'A',Utl �CURRENT FORM IA' HAS BEEN FILED DATA PROCESSING COPY