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'_ _ %' �e.�or+-.s -. ..,�,-��.r.,.� ,.,, ,ri,.• ,,, ,;fiT'!` 'v'`il'-`" '=�`lrfSra'`.F..Y�ifr-.,.T�A��. •Yr--•�: ,.'� STATE OF CALIFORN" WATER RESOURCES CONTR RD '- FORM 'S': UNDERGROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIX INFORMATION FOR EACH TANK. ; I[7 MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED J CA3 FACILITY/SITE NAME WHERE TANK IS INSTALLED: �j FARM TANK-YES NO ❑ F�J��I 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 00 00 A OWNERS TANK ID N B. MANUFACTURED BY: C.YEAR INSTALLED D.TANK CAPACITY IN GALLONS: If. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8,C.A.S.N C.A.S.N. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D A TYPE OF ❑I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑I STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVIM'LCHLORIOE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑I RUBBERLINEO ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLICLINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERfAL COMPATIBLEWITH ICO%MEIHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑I POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 LNAAUNN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A V 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY.OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ND GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. APPLICANT'S NAME IPRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N [a I I -] I I I I I Ll 12/1 / 1 -5-Mlo DT CURRENT LOCAL AG N FACILITY ID N 6114L� n^ \ APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRA ION DATE CHECK 0 PERMITAMOUNT SURCHARGE AMT. FEE COOS RECEIPT 0 BY: FORM D(6-2988) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM'A',UNLESS A CURRENT FORMA' HAS BEEN FILED -A nVC01k1r`r^r1DV