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STATE OF CALIFORN_ WATER RESOURCES CONTR BOARD "^ FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION % '�' OMPLETE A SEPARATE FORM WITH THE FOLLOWIN!12! 1 ORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED 6 FACILITY/BITE NAME WHERE TANK IS INSTALLED: y,�?Y j, t//) «fD FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY P F� A. OWNERS TANK 10 R B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: G, 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM A. EZI MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL ❑ B.3 CHEMICAL PRODUCT ❑ 4 OIL I PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 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 S CA.S.R C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A B,C,s D A TYPE OF ❑ 1,96ALEWALLM ❑3 SINGLE WALLED PATH EXTERIOR UNION ❑95 UNKNOWN SYSTEM L 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER I STEEL/IRON ❑2 STAINLESS STEEL EE'3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MAMATERIALF-15 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ i ALUMINUM ❑B 100%METHANOL COMPATIBLE TRP ❑9 BRONZE ❑ 10!!=STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERUIED ❑2 LINING ❑3 EPDXYUmNO ❑ 4 PHENOLIC LINING LINING ❑ 5 GUSS UNING 6 UNLINED ❑95 UNKNOWN ❑ISUNNGMATERkcc)MPATIBLE WITH t(IMMETHANOL? ❑YES ❑NO ❑99 0 FPROORTEOCI ION ❑ I POLYETHLETIE WRAP ❑2 TAR 6A ASPHALT ❑ 3 VRM WRAP /FIBERGLASS REINFORCED PLASTIC THIN ❑5 CATHODICPROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATI CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE Acu I SUC710 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 NK O A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE C.MATERIAL A U 5 NLMINUM A U 11-CONGPIFiF A U ?STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 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. P E I VISUAL CHECK P E 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P S 4 ELEC MONITOR P S 5 GROUND WATER MONITORING WELLS p-1"PRECISION TESTING P S 7 PRESSURE TESTING P E 91 NONE P CC 95 UNKNOWN j P E 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONR) 2. ESTIMATEDOUANTITYOF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY E JURISDICTION E AGENCY P FACILITY ID S TANK ID P CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK F PERYA AMOUNT SURCHARGE AMT. FEE CODE RECEIPT F FORM B 1e-mm) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILEO DATA PROCFASINn T.nPV