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STATE OF CALIFORNi WATER RESOURCES CONTR BOARD FORM 'S': UNDERGROUND 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 INFORMATION ❑ 7 p gNENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK flEMOVED f��,' FACILITY/SITE NAME WHERE TANK IS INSTALLED: c CA FARM TANKNO ❑ YV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p B. MANUFACTURED BY: O C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A/),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 ❑ 1 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&C A.S.W CAS N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TA�RIAL ❑5 CONCRETE E]6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS DINING MATERIAL COMPATIBLE WITH Ion METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP ❑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 I 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 B CONCRETE A U ] STEEL CLAD W/FRP A U 8 100%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 / VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION Y AGENCY S FACILITY ID R TANK ID S %' = = I I I �z a 3 s CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHI WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERU/IT EXPIIIATION DA CHECKS PEgYR AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(8-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY