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. lrATE OF CALIFORNIA WATER RESOURCES CONTROL BOOP <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM -eo <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MMK ONLY m I NEW PERMIT ❑3 REEWALPEIMR ®6 CHANGE OF WFDRMATDN ❑7 PERMANENTLY CLOSED TANK <br /> ONE ITEM 2 INTERIM PERMIT ❑4 AMLNDFDPERMR ❑6 TEMPORARY TAN(CLOSURE ❑8 TANK REA DVED <br /> zliFACILRTIMSITE NAME WHERE TANK IS INSTALLED: X1C - S 7-"17 3 FARM TANK-TE6❑ NO <br /> L TANK DESCRIPTION COMPLETE ALL ITEYt-IFUNMOWN-SOwEaFY <br /> A.OWTIERS TANK 10 9 B.MANUFACTURED BY: Cp Y N 1 k r P �<P` <br /> C.YEAR ilSTALJ.ED C. <br /> TANK CAPACITY IN GALLONS: /cj o G c. <br /> IL TANK CONTENTS K(ALlh IS MARKED,COMPLETE ITEM C.N(A.0 98 NOT YANKED,COMN.ETE ITEM 0. <br /> A T MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ®1 UNLEADED ❑2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT ❑N OIL ©1 PRODUCT ❑1 OASAHOI ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE N ITEM 0.BELOW) <br /> 0, IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF GAS 9: <br /> HAZARDOUS SUBSTANCE STORED 6 CAS.9 <br /> 111. TANK CONSTRUCTION MARK DINE ITEM ONLY IN BOX A,9,c,A 0 <br /> A TYPE OF <br /> 01 wimEwAun F-13 BI/(RE WAU89WT HEAIBtlOHUER ❑95 UF9E01WI <br /> SYSTEM El2 SR49E WALLED ❑A 6ECONOMNCONTA" M ❑M ORER <br /> ❑I STEUPON ❑2 STA9AF55 STM ®3 FBEgaM ❑N SMaADWMBMASSREMnMRISTIC <br /> S.TAM( ❑5 DONLTETE ❑6 POLyVWLMOROE ❑7 ALM MM ❑9100E11ETIUN D)WATWITIP <br /> MATERIAL ❑9 BRONLZE ❑10 GALVAMZM STEL ❑95 UKNOML ❑19 OVEN <br /> ❑I Ras Lmm F-1 2 AU(TD LINK ❑3 EPDXY W% ❑1 RIENOUCUHNG <br /> C INTERIOR ❑LINING 5 GLASS Lw g 6 U&M E)95 IP93E7AN <br /> ❑IS LMNG MATERALCOMPATBLE WITH 100E AIETIMNOL? ❑YES ❑NO ❑99 OTHER <br /> 0.CORROSION ❑I POLYETNLfWWNAP ❑2TAR OR ASPHALT ❑3VMFl WRAP N FIBHiGIASSIEIM0'MPUZK <br /> NIOTECTION ❑5 CATHODCPROTECTDN ❑91 NONE ❑95 M9010WN ❑99 Of <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND. U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U I SUCTION A 2PRESSURE A U 3 GRAVfTY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U "OTHER <br /> S.CONSTRUCTION A Y 1 SINGLE WALLED A U <br /> A U I STEELARON A U 2 STAINLESS STEEL A V 3 POLYVINYLCHLORIDE(PVC) A(9) 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FAP A U a J0 METHAHOLCOMPATIBLEMP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U N OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR 8 FOR SECONDARY.A PRIMARY LEAK DETECTION STSTEY MUST BE CIRCLED. <br /> P O I VSUAL CHECK P�2 INVENTORY RECONCILIATION P 9 3 YADOSE WELLS O 6 A ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS <br /> P 9 6 PREGSKM TESTING P 9 7 PRESSURE TESTING P 6 91 NONE P / 95 UNKNOWN P 6 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALS ME"MATERIAL? [:]YES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AjjD TOITZ BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE / <br /> G.J. MEYEfl-U.GT.ANAIYST i3 9a <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 9 JURISDICTION E AGENCY I FACILITY 101 TANK IO 9 <br /> CURRENT L AL AOENc FACILITY I I A OVED sY 1FAMC PHONE E WITH AREA CODE <br /> Pfl1YR NUYSER PERMIT AMIIOVAI GATE RRYR E]DMMTION DATE <br /> CNAECK 6 PERYR AMOUNT 9URCHARDE AYR. EEE CODE <br /> RECEIR P 9Y: <br /> { . <br /> F B(6.nml THISFORMMUSTSEACCOMPAl FACLITYAUTEANIICATIOK, FORM'A'.(MESSACUNWIT F011W NASKENFILED !� <br /> 1 DATA cSSING COPY 2 IACAL AGENCY= copy <br />