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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION a COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO E O ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT B TEMPORARY TANK CLOSURE ❑B TANK REMOVEDLn Ircn� FACILITY/BITE NAME WHERE TANK IS iiiTALLED: ` ;�e FARM TANK-YES E] NO rN FV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A 1� A. OWNERS TANK ID E B. MANUFACTURED BY: ulC, (TT C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: JU J 11. TANK ICONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUMB. C. ❑(UNLEADED ❑2 LEADED ❑3 DIESEL FD CHEMICAL PRODUCT ❑1 OIL " 1 PRODUCT ❑/ GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 90 EMPTY 0 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 S C.A.S.! C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,8,C,a D A TYPE OF ❑ I WALLED ❑3 SINGLE WALLED WITH D IERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER F-11 SFEEUIRON ❑2 STNNLESSSTEEL ❑3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK YMATERIALEl5 CONCRETE ❑9 POLYWNYL CHLORIDE ❑ 1 M ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL LPNK N ❑99 OTHER ❑ G INTERIORI RUBBER LINED ❑2 AMD LINING ❑3 EPDXY LINING ❑ 1 PH 1C LINING LINING F-16�LNNG ❑9lMLINEO UNKNOWN ❑B LINING MATERIAL COMPATIBLE WITH IOD%MEfHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYERAENEWRAP ❑2 TAR OR ASPHALT 3 VI ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTEC110N ❑91 NONE 11 L145 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 U9 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A Lr95 UNKNOWN U 99 OTHER A U 1 STEFUIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U / FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U S A U / STEEL CLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 OALVANIZED 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 B 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P B / ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P t 8 PRECISION TESTING P B 7 PRESSURE TESTING P ! 91 NONE P-285 1CGNK— NOW P E 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF3. WAS TANK FILLED WITH GALLONS REMAINING IN INERT MATERIAL? ❑YES [:]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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY E JURISDICTION P AGENCY E FACILITY ID B TANK ID P CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE F WITH AREA CODE 7 F PERMIT NUMBER PERMIT APPROVAL DATE PlRMIT EXPIRATION DATE CHECKF PERMIT AMOUNT ^URCHARGE AMT. FEECODE _ -CEIPT0 BY: "j FORM B 1029-8M THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA DRnrennl r.nov - -- -