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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM A` TANK .1� TANK PERMIT APPLICATION I RMATION mho d6111101.0i A>�!:'PANAtt FORM WITH THE FOLLOWING FOIIMAT)ON FOIL EACH TANK. " MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT "HANGE OF INFORMATION ❑ 7 PERMANENTLY C K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOV FACILITY/SITE NAME WHERE TANK 18 INSTALLED:, '^ FARM TANK-YES O I. TANK DESCRIPTION COMPLETE ALL ITEMS-6F UNKNOWN-SO SPECIFY g r • L-6fC� GL A. OWNERS TANK 10 E B. MANUFACTURED BY: C. YEAR INSTALLED I D. TANK CAPACITY IN GALLONS: 0 11. TANK ONTENTS 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. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT F] 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) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N OA S.N: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXIERIL LINES ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 SIEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 1D0%METHANOL COMPATIBLE FRP MATERIAL `❑9 BHONff ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑ 4 PHENOLIC LINING C. INTERIOR5 GLASS LINING El UNLINED [:]95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 10016 METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETH-MWAAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 RBERGLASSREINFOPCEO PLASTIC PROTECTION ❑5 CATHODD 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 DOUBLE WALLED 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 9/ NONE C. MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL A U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR A FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S / VISUAL CHECK P B 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YFO 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLON$ INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE 1 LOCAL AGENCY USE ONLY COUNTY E JURISDICTION S AGENCY# FACILITY ID S TANK ID S CURRENT LOCAL AGENCY FACILITY IDI �& I APPROVED BY NAME PHONE F WIT"AREA CODE PERMIT NUMBER /`J PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK P PERMIT AMOUNT It AMT. FEE CODE RECEIPT E BY FORM 6(6-29-88) THIS FORM MUST BE ACCO MPANI�Y A FACILRYAITE APPLICATION, FORM'A',UNLESSrCGRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY