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J I A I t OF CALIFORNIA WATER RESOURCES CONTROL 130ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANS( TANK PERMIT APPLICATION INFORMATION �o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 HEN AL PERMIT ❑ 5 CHANGE OF INFORMATION .. ONE ITEM 21NTERI ❑7 ENK REM ANK ❑ INTERIM ❑q AMENDED ❑ 6 TEMPO�ARYTANKCLOSURE 6 TANK REMOVE GI FACILITY/SITE NAME WHERE TANK IS INSTALL ED: Fy S7 FARM TANK-YES❑ NO 7q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p B. MANUFACTURED BY: G7 C. YEAR INSTALLEDG) D. TANK CAPACITY IN GALLONS: Q .� 11. TANK CONTENTS IF(A.1),IS MAR ED,CO PLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE 1 EM 0, II . O A. 1 MOTOR VEHICLE FUEL 2 PETROLEUM ul B. C. ❑ 1111,11 EADED 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASOHOL 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 A C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF WM I FD ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 NGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER 1 STEEL/IRON ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC 9.MATTERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN [:)99 OTHER C. INTERIOR ❑ 1RUBBEA LINED ❑2ALKY0LINING ❑3EPDXY LINING ❑ LIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 10%,METHANOL? YES ❑NO 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VI WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 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 W OTHER A U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEFLCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 3 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 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 SUBSTANCE REMAINING IN INERT MATERIAL? yES NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FALIQ/ D 11� APPROVED BY NAME PHONE S WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK Y PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTS Bv:BY: (Z FORM B(6-29-86) THIS FORM MUST BE ACCOMPANII. Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AZbBRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY