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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 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 El// PERMANENTLY CLOSED TANK ONE ITEM ❑ 2INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE I' 8 TANK REMOVED Q 9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: V F1 I - FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# u/ B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. �y, Cp A. LIQ ' MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL t ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ i PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS �•! ❑5 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.# CA.S.#: xl I I. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A. TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH RTERIOR UNER ❑95 UNKNOWN SYSTEM V2 SINGLE WAUED ❑4 SECONOARVCONTAINAENT ❑99 OTHER STEEL/IRON ❑2 STAIMESSSTEEL ❑3 RBERWSS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 1011%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STETi ❑95 UNKNOWN ❑99 OTHER it C. INTERIOR ❑ 1 RIBBER UNE) ❑2 ALKYD LINING ❑3 EPDXY LINING ❑�4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED 1 �'°UNKNOWN ❑ IS LINING MATEMAL COMPATIBLE NTH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOgCPROTECTIaI ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDERGROUND,BOTH IFAPPLICA13LE A SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCHAe% 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AOU 95 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. 8 / VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTING P 8 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 A� SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ NO /� OALLONB THIS FORM HAS BEEN COMPLETED UNDER PENALTY 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# 371 00 LL AOENCYFACILITYIDN APPROVED BY NAw1vPHONE#WITH AREA CODE n R PERMIT APPROVALD PERMITEXPIRATIONDATE PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIE-LOA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A77GIRENT FORMA' HAS BEEN FILED "EBBING COPY