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TT STATE OF, OALIFORNI. WATER RESOURCES CONTROOARD FORM 'S': UNbERGROUNb STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION tf001.09 A*90ARATE FORM WITH THE FOLLOWING INFORMATION POR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑9 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY C 0 ONE ITEM ❑2 INTERIM PERMIT ❑d AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES 0 I. TANK DESCRIPTION L COMPLET AL TEMS.IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDB 77TB MANUFACTURED BY: � . C. YEAR INSTALLED L 7 D. TANK CAPACITY IN GALLO : /OO O 11, TANK CONTENTS IF(A IS MARKED, MPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ull A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED DED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑d OIL ❑ I PRODUCT ❑4 CASA 5 JET FUEL 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A CAS.0 C.A.S.If: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN Box A,B,C,A D A TYPE OF ❑7 DOUSLE WALLED ❑3 SINGLE WALLED WITH DaRIOR LINER ❑95 UNKNOWN SYSTEM M SINGLE WALLED ❑/SECONDARY CONTAINMENT ❑ 99 OTHER I STEEUIRON 2 STAINLESSBTEEL ❑3 FIBERGLASS ❑1 STEEL CLAD WNIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑0 POLYVWL CHLORIDE F-17 ALUMINUM ❑B 10096 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALKYDLINING ❑3 EPDXY LINING ❑/PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYEDRENE WRAP ❑2 TAR OR ASPHALT F-�3 VINYL WRAP /FIBERGLASS REINFORCED PLASTIC PROTECTION ❑S CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE A U 1 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 DOUBLEWALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A U d 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 U 99 OTHER V. LEAK DETECTION SYSTEM' CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 d ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 6 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 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 GALLONS ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE I LOCAL AGENCY USE ONLY COUNTY F JURISDICTION S AGENCY K FACILITY ID P TANK ID 8 CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE " CHECK0 PERMITAMOUNT SURCHARGEAMT. FEE CODE ECEIPTIf lkvv/ FORM 8(8-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY