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STATE OF CALIFORNI WATER RESOURCES CONTROL6►RD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM Qp TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EAC"TANK MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ®5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT E]A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q I FACILITY/SRE NAME WHERE TANK IS INSTALLED: F xk -'-�'�� FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—BO SPECIFY A. OWNERS TANK ID N 8. MANUFACTURED BY: ;1 t > C.YEAR INSTALLED 1 1 O. TANK CAPACITY IN GALLONS: �- 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE REM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. A. ❑1 MOTOR VEHICLE FUEL ❑ 1 2 PETROLEUM B. C. .^, UNLEADED LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑A OIL © 1 PRODUCT ❑A GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑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 8 C AS.N CAS,N: 111. TANK CONSTRUCTION MARK ONE;—,.99 ONLY IN ZPOK A,B,c,a D A TYPE OF I DOUBLE WALLED ❑3 SNGLE WALLED WITH EXTERIOR LINER ❑95LNKNOWN SYSTEM ❑2 SINGLE WALLED ❑A SELONDAR/CONTAINMEM ❑99 OTHER ❑ 1 STEEL/R)N ❑2 STAINLESS STEEL ®3 FIBERGLASS ❑A STEEL CUD WIRBERGUSS REINFORCED PLWIC E.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ i ALLIMNUTA ❑B 100W METHANOL COWPATISLE FRP MATERIAL ❑9 NgI11E ❑ ID GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RIBBER LINED ❑2 A1KY0 UNING ❑3 EPDXY LINING. ❑A PHENOLIC UNING C.INTERIOR F-15 GLASS LINING 6 UNUNED EJ%UNKNOWV ING ❑SLININGWTERMLCOMPATIBUWRHIDULMETMNOL? [:1 YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYEIRLENE WRAP ❑2 TARORASPHALT ❑3 WNYLWMP ®A FlBERGUSS REINFORCEDPWTIL PROTECTION ❑5 CATHOOICPROTECTION ❑91 NONE ❑%UNKNOWN ❑%OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A 9 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U M 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 M UNKNOWN A U %OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A(9) A FIBERGIASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U 8 19 METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U %UNKNOWN A U %OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P ¢1 1 VISUAL CHECK P`A;2 INVENTORY RECONCILIATION P E 3 VADOSE WELLS CP'E A ELECTRONIC MONITOR P A 5 GROUND WATER MONITORING WELLS A 6 PRECISION TESTING P S 1 PRESSURE TESTING P S 91 NONE P A %UNKNOWN P E 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE UST USED IMO/YR) 2 ESTIMATED QUANTITY OF 3. WAS TANK FILL EO WITH SUBSTANCE REMAINING IN)' N GALLONS INERT MATERIAMATERIAL? ❑YES E:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AVTO)Tdk BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE G.J. MEYER-U.G.T.ANALYST J3190 LOCAL AGENCY USE ONLY COUNTY F JURISDICTION E AGENCY F FACILITY ID R TANK ID N m = = I I I iz- CURAE LOCAL AppG^y NCY FACILITY ID A APPROVED BY NAPE PHONE F WITH AREA CODE r`� PlAYR MUYSlR PERMIT AM110YAL DATE PEAYR QPMATON DATE CHECK# PERMIT AMOUNT WACHAROE AMT. RECODE RECEIPTS �L I �EORms(629m) THIS FORM MUST BE ACCOM►ME'„A FACLITYAITI MSUGTioK FORM'A',LKMApr-'MT FOW'A IWBFENFKED DATA PIESSING COPY LOCAL AGENCY COPT •FLE COPY �/I