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STATE OF CALIFORN' % WATER RESOURCES CONT' l BOARD FORM 'S': UNDIRGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. _ z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION4 0 ONE ITEM ❑ 7 PENCLOSED TANK 2 INTERIM PERMIT �/AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE �B TANKK REMOVE REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: W FARM TANK-YES O ❑ I-.► 1. TANK DESCRIPTION COMPLETE ALLITEMS-IF UNKNOWN—SOSPECIFY A. OWNERS TANK ION ----FBMAN00 UFACTURED BY' N C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 7 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 C.A.S.a C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.S D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH DaERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER E] I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC 6.MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER UNED ❑ 2 ALKYD UNING ❑3 EPDXYLINING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNUNED ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYEMLENE WRAP ❑2 TAR 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 10 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 3 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P B 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 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(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION B AGENCY S FACILITY ID 0 TANK ID a CURRENT LOCAL AGENCY FACILITYIDF APPROVED BY NAME ,.i HONE 0 WITH AREA CODE In PERMIT NUMBER PERMIT APPROVAL DATE PER TEXPIRATION TE CHECKI PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY; FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED A___ __ __ DATA PROCESSING COPY