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STATE OF CALIFORNI WATER RESOURCES CONTRO ARD <br /> FORM 'S': UNDE ROUND STORAGE TANK PRONAM M 'm <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I <br /> NFORMATION FOR EACH TANK. <br /> MARK ONLY NEW PERMIT F-]3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑2 INTERIM PERMIT [-] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED a <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: , - ' FARM TANK-YES❑ NO Er <br /> z <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY I Cy <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ,900 <br /> 11. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. Qp <br /> A. 1 MOTOR VEHICLE FUEL F-] 2 PETROLEUM B. C. 1 UNLEADED 0 2 LEADED ET3 DIESEL <br /> 7 3 CHEMICAL PRODUCT F-�4 OIL P ' 'PRODUCT ❑4 GASAHOL 5 JET FUEL [::] 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS [::] 80 EMPTY [::] 95 UNKNOWN 2 WASTE 7 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.# 4 <br /> C.A.S.#: <br /> x111. TANK CONSTRUCTION MARK ONE I EM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF F071 DOUBLE WALLED F-1 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER <br /> LII ' STEEL/IRON ❑2 STAINLESS STEEL F-]3 FIBERGLASS 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MATERIAL 5 CONCRETE ❑6 POLYVINYL CHLORIDE F-17 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> 9 BRONZE El 10 GALVANIZED STEEL [::]95 UNKNOWN 99 OTHER <br /> C.INTERIOR 1 RUBBER LINED F-] 2 ALKYD LINING F-13 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING F-1 6 UNLINED 95 UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION D 91 NONE 95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A M, <br /> SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B.CONSTRUCTION A&A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 <br /> C. MATERIAL A U 5 ALUMINUM A U,6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 5 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 /> ]:[aS <br /> VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE ST USED(MO/YR) 2. ESTIMATED QUANT TY OF 3.WAS TANK FI ED WITH <br /> I SUBSTANCE E NI G IN GALLONS �J@J A INERT AQA�E IqQ? YES NO <br /> J� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERAW AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK IID`# <br /> -1 E[ I LE [() 10 (� Q <br /> :l <br /> CURRENT LOCAL AGENCY FACILITY ID# APPRO(ED,Y 14 ME PHONE#WITH AREA CODE <br /> FPA `z I 'F caff- <br /> PERMIT NUMBER PERMIT ARPROVAL D//ATE PERMIT EXPIRATION DATE <br /> L� <br /> CHECK# PERMIT AMOUNT SURCHARG A L FEE CODE s RECEIPT# BY: <br /> FORM B(3-7-88) THIS FORM MUST BE ACCOMPANI A FACILITY/SIT@ APPLICATION, FORM `A',UNLESS ENT FORM`A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />