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STATE OF CALIFORN' WATER RESOURCES CONTFi BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK , TANK PERMIT APPLICATION INF MATION a COMPLETE A SEPARATE FORM WITH THE FOLLOWING ORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED //o'j FACILITY/BITE NAME WHERE TANK IS INSTALLED: ( G/y S FARM TANK-YES❑ NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A A. OWNERS TANK IDE B. MANUFACTURED BY: C. YEAR INSTALLED L D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. 7EAHOL EADED ❑ 2 LEADED DIESEL ❑ 3 CHEMICAL PRODUCT ❑1 OIL 1 PRODUCT ❑ 5 JET FUEL ❑B AVIATION GAS 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTEHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BElOW1 D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 CAS.R C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C.A D A TYPE OF ❑ I))dJBLEWALLS) ❑3 SINGLE WALLED WITH EXTERIOR UWR ❑95 UNKNOWN SYSTEM L 2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEURON ❑2 STAINLESS STEEL 3 RBEROU.SS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC I.TANK ❑5 CONCRETE ❑9 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE/ ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR n'V1114AUNED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑/PHENOLIC LINING LINING 5 GLASS UMM3 ❑e UMUNED ❑95 UNKNOWN , ❑B UNING MATERIAL COMPATIBLE WITH IDO%METHANOL7 ❑YES ❑NO 0990 F IIROSION ❑ I POlYE118ENEWRAP ❑2 Th110R ASPHALT ❑3 VINYL WRAP /FIBERGLASS REINFONCEO PIASIIOOTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATI LE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE I A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 U 95 UNKN A U 99 OTHER A U I STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEELCUD W/FRP A U 8 ID METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 5 UNKN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. LP S I VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P �_ELECTBONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P 6 6 PRECISION TESTING P 6 7 PRESSURE TESTING P S 91 NONE _P 95 P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE UST USED(MO/YR) T 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? E]YES L) 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYC jE JURISDICTION E AGENCY E FACILITY ID E TANK ID E II V CD C) CURRENT LOCAL AGENCY FA/C�ILIT.Y/ID/ APPROVED BY NAME PHONE 9 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK E PERYR AYOUNT SURCHARGE AMT. FEE CODE RECEIPT N pY• LL FORM B(a 29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED nATA PnnrocslNr-rncv