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STATE OF CALIFORNI WATER RESOURCES CONTR( 30ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION EVIPERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE El 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I;Fql)O FARM TANK-YES NO ❑ c N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W 0 F-&` A. OWNERS TANK IDM B. MANUFACTURED BY i N C. YEAR INSTALLED G{/Ulh-/ D. TANK CAPACITY IN GALLONS. �5C7 II. 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 j ❑5 HAZARDOUS ❑ 80 EMPTY [El 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&C.A.S.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,9,C.&D A. TYPE OF ❑ 1 UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEL/IRON ❑2 STAINLESSUEEL ❑3 FIBERGLASS ❑4 FEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIAL 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ED0100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEN ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑ LKYOUNING ❑3EPDXY LINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LININGNUNm ❑95 NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 990 R f D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TARORASPHALT Qk VINYL WRAP ❑4 RBERGLASS REINFORCED PLASTIC PROTECTION ❑5 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 HE UNKNOWN A U 99 OTR B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL if95 UNKNOWN A U 99 OTHER V./LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1VISUAL CHECK P S 21NVENTORY RECONCILIATION 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 SGROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI TED DATE LAST USED(MONA) 2. ESTIM TED QUANTITY OF 1 3.WAf TANK FILLED WITH SUB E REMAINING IN MATERIAL? E-]YESE]NO VIA A GALLONS THI FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FACILITY ID# VBD�BY AM ) PHONE N WITH AREA CODE PERMIT NUMBER -71 PERMIT APPROVAL DATE �j/J�I PE MIT EXPOtATION DATE CHECK N I SURCHARGE AMT. FEE CODE I RECEIPT FORM a(6-29-Ba) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM A',UNLESS7l CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY