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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM `yam TANK TANK PERMIT APPLICATION INFORMATION $% ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P ANENTLY CL MARK ONLY ❑ ❑ ❑ G ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED 0 / / � W FACILITY/SITE NAME WHERE TANK IS INSTALLED: S0 ` e� - FARM TANK-YES NO ❑ C,,) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY /„w —4 A. OWNERS TANK ID R B. MANUFACTURED BY: 00 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: O 11. TANK cowrtNTS IF(A•1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM C. ❑ 1 UNLEADED 2 LEADED E:] 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL B.;9"1PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ❑ SO 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 8 C.A.S.A C A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WAILED WITH EXTERIOR LINER UNKNOWN SYSTEM [:]2 SINGLE WALLED ❑4 SECONDARYOONTAINMENT ❑ 99 OTHER ❑ 1 STEELIIRDN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE E]6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100%METRANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 2 ALKYD LINING E] 3 EPDXY LINING ❑ 4 HENGUC LINING C. INTERIOR LINING F-15 GIASSUNING 6 UNUNED 7UNK14OWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO D 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT3 LWRAP E] 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN E] 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 I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 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 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10096 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 IVISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE UST USED(MO/YR) 2.ESTIMATED QUANTITY OF 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. APPLICANT'S NAME(POINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION E AGENCY P FACILITY ID B TANK ID P F71 CURRENT LOCAL AGENCY FAC1 8 APPROVED BY NAME PHONE 0 WITH AREA CODE Ll 2 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK 0 PERMIT AMOUNT SURCHAgGE ANT. FEE CODE RECEIPT t BY FORMB(6-29-88) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED DATA PROCESSING COPY