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STATE OF CALIFORNM ''I, WATER RESOURCES CONTR BOARD FORM 'S': UNDtRGROUND STORAGE TANK PROGRAM ; TANK �/ TANK PERMIT APPLICATION INFORMATION (a" COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF RMATION FOR EACH TANK. z O MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY NK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOV FACILITY/SITE NAME WHERE TANK IS INSTALLED: j Y q F57 J A (-.�3 FARM TANK-YES gft"NO ❑ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECT �5-30 y A. OWNERS TANK IDp B. MANUFACTURED BY: C.YEAR INSTALLED - D. TANK CAPACITY IN GALLONS: II, TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑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 ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8,CA.S.K C.A.S.K: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C.8 D A TYPE OF ❑ I DOUBLE WALED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT E]99 OTHER ❑ I STEEURON 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑5 OOWATE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑81D0%METHANOL COMPATIBLE FRP MATERIAL.. ❑ 9 BRONZE ❑ IB GALVANIZED STEEL ❑95 UNKNOWN ❑MOTHER C. INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS UNING ❑6 UNUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑ NO ❑99 OTHER 0.CORROSION ❑ 1 POLYETHLENEWAAP - ❑2 TAA OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 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 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 16 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 9/ NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. 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 ANO CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION B AGENCY K FACILITY ID B TANK ID B ® 166 6 1 o0 CURRENT LOCAL/ CT FACILITY ID APPROVED BY NAME PHONE Y WITH AREA CODE os / PERMIT NUMBER ' PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 41 CHECK Y PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT Y By; n FORM B(6-29.88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY