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<< STATE OF .CALIFQRNI���' � ;waTER RESOURCES coNTRrBOARD <br /> FORM 'S': UNDEr�GROUND STORAGE TANK PRRAM <br />' TANK PERMIT APPLICATION INFORMATION . <br /> ,,TANK.; , . COMPLETE A SEPARATE FORM WITH THE:FOLLOWIN ORMATION FOR EACH TANK. <br /> I, <br /> MARK"ONLY 1:11 <br /> NEW PERMIT, ❑3 RENEWAL PERMIT 5CHANGf OF INFORMATION ❑/TANK <br /> MANENTLY CLO <br /> ONE:ITEiM- ❑2 INTERIM PERM, ❑4 AMENDED PERMIT ❑`6 TEMPORARY TANK CLOSURE 8 REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: h/sv"i }FARM TANK-YES❑ NO W, <br /> wr L TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—80 SPECIFY <br /> A. OWNERS TANK 10#. �? B. MANUFACTURED BY: (� SID } <br /> C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> Q I <br /> II. TANK.CONTENTS 'IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL"❑ 2 PETROLEUM B. EEO] <br /> 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL <br /> 3CHEMICAL PRODUCT ❑ 4 1L ❑ 1 ODUCT ❑ 4 GASAHOL ❑5 JET YFUEL ❑6 AVIATION GAS <br /> 5 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL ❑99 OTHER JDESCRIBE IN ITEM D.BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.it C.A.S.W <br /> III. TANK CONSTRUCTI !MARK ONE ITEM ONLY IN BOX A,8,C,&Dol " <br /> X <br /> 1 PLE>LED, 3 SINGLE WALLED WITH EXTERIOR LINER <br /> A TYPE OF ElE❑95 UNKNOWN r I' <br /> SYSTEM .' SI WALLS] ❑4=NDARY CONTAINMENT II❑ 99 OTHER <br /> 1 STEEUIRDN ❑2 STAINLESS STEEL ❑3 FIBERGLASS i€❑ 4 STEEL.CLAD WIRBERGLASS REINFORCED PLASTIC <br /> B.TANK " 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM it❑ B 10096 METHANOL COMPATIBLE FRP <br /> MATERIAL •..'- _ I <br /> ❑9 BRONZE; ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER <br /> F <br /> ❑ 1 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PH LINING <br /> C.INTERIOR <br /> LINING, ❑5 GLASSUNING ❑8 UNLINED I"� UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 103%METHANOL7 ❑YES NO !❑99 OTHER <br /> D.CORROSION",- El 1 POLYETHLFNE WRAP ❑2 TAR OR ASPHALT ❑ 3 WRAP II❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER F <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROU I�BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAOTO A U 91 NONE A U 95 UNKNOWN A U'99 OTHER <br /> B.CONSTRUCTION. A !C2:S:lNGL9WALCE-DN A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER ; <br /> A /lR A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C.MATERIAL A U A U 6 CONCRETE A U 7 STEEI'ICLAD W/FRP A U 8 I100%METHANOL COMPATIBLE FRP <br /> i <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 8 1 VISUAL.CHECK P 8 2 INVENTORY RECONCILIATION lADOSE WELLS P 8' 4 ELECTRONIC MONITOR P 8,i�5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P S. 95 UNKNOWN P S.:99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE f <br /> 1.ESTIMATED.DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF ; 3.WAS TANK FILLED WITH <br /> r <br /> SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO <br /> GALLONS ,j <br /> i <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT.. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE it ' <br /> ' LOCAL AGENCY USE ONLY <br /> COUNTYA JURISDICTION# AGENCY# i FACILITY ID# TANK ID 0 <br /> . oEd y ��,,: ,Y 1'0101 3 <br /> [URRIINT LOCAL AGENCY FACILITY 10/ APPROVED BY NAME PHO_NE R WITH AREA CODE <br /> T NUMBER. PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> # PERMIT AMOUNT J—'tURCHARGE AMT. FEE CODE RFCEIPT 6 1 BY:. + <br /> FORM B(6-29.66) THIS FORM MUST BE ACCOMPANIE A.FACiLITYISITE APPLICATION, FORM `A',UNLESSYRENT FORkI'A':'HAS BEEN FILED <br /> ''. '^,,,,.� <br />