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STATE OF CALIFORI X WATER RESOURCES CONY BOARD ••'`.•�.b , <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM . w <br /> TANK PERMIT APPLICATION INFORMATIONo <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. 4 Z' <br /> G <br /> MARK ONLY ❑) NEW FFT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY K <br /> ONE ITEC! [32 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOY <br /> W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: �Sr $g� FARM TANK-YES . NO ❑ [� <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY ��� cc <br /> F <br /> A. B. MAN <br /> OWNERS TANK IDN UFACTURED BY: Cc <br /> C.YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS W`AA).IS MARKED.COMPLETE ITEM C.IF(A.1).Is NOT MARKED.COMPLETE ITEM D. <br /> A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑t UNLEADED ❑2 LEADED ❑3 DIESEL <br /> 3 CHEMICAL PROD= 4 OIL i PRODUCT ❑4 GASAHM ❑5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 KQARDOUS [:D 80 UWTY [:]95 LOIKNOWN C]2 WASTE ❑T METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.N: <br /> 111. TANK CONSTRUCTION MARK ONE TIEM ONLY IN SO%A,B.C.&D <br /> A TYPE OF ❑I DOUBLE WALLM ❑3 SINGLE WRiED WRH EXTERIOR LRO ❑95 IR1KI om <br /> SYSTEM ❑2 SNGLEwwo ❑4 SECOW1 NCONTAINMENT ❑99 OTHER <br /> ❑1 STEElllR011 ❑2 STAi1flES5MR ❑3 RBMLASS ❑4 STF.B.CWIwfFIeER ASSWFORc1DPLASTIC <br /> S'TANK ❑5 COIICgETE ❑ <br /> MATERIAL 8 POLMNYLOWKIE ❑7 N N ❑8 IW%ME IWa0OWATSI.EFRP <br /> :. . M8 <br /> ❑9 BRDNIE ❑tO GALVAWZEO Sff L ❑96 UWJaM, ❑99 OTHER <br /> INrERiOR ❑ 1 MmLYIED ❑2 AM UMNG ❑3 EPDXYUWNG ❑4 P143tXCLIWNG <br /> LINING ❑5 OLAWUNI fi ❑B LI+ to - ❑95 UW(II m <br /> ❑IS LNM MATHEAL ODWAME WITH 1891E MEIIIA M? ❑YES ❑N ❑99 OTHm <br /> L CORROSION ❑I POLYSTtf$i WW ❑2 TAR OR ASPHALT ❑3 VWWRAP ❑4 fwm&%R Oi1CI31PLASnc <br /> PROTECTION ❑S CATNDDICPROTECROR ❑91 NNIS ❑95 IA#(H o ❑99 OT1ETi <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A.SYSTEMTm A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SNOLE WAILED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C+.MATERUU. A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/fes A U 8 10076 METHANOL 0OWATmLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P 9 2 INVENTORY RELONCUjATKNd P i a VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS <br /> t's S PRECISION TESTING P i ?PRESSURE TESTING P 8 41 NONE P S 95 UNKNOWN P E SOOTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSEDIN PLACE <br /> L <br /> ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3,WAS TANK FILLED WITH <br /> SJBSTANCE REMAINING IN QALLON6 INERT MATERIAL? ❑YES [:]NO <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLIGANT"S NAME(PRINTED 6SKiNATURE) DATE. <br /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M AGENCY# FACILITY ID# TANK ID# <br /> L T-1 i <br /> Fo7o­ <br /> �J-/ z f <br /> C) CURRENT LOCAL AGENCY FAC 1TY to " APPROVED BY NAME PHONE it WIY11 AREA CODE <br /> . 6. -9;r-7 <br /> PERMITNUMBU PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK i PERMIT AMOUNT SURCBARGE AMT. FEE CODE RECEIPT 0 bY: <br /> FORM B(8-29-011) TNIS FORM MUST BE ACWWANIFB BY A FACILIMMT,sa W'ATh,M <br />