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I h I Q Vr WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK '` TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2INTERIM PEHMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 4.5-7:Z7,11 ( FARM TANK-YES❑ NO ❑ �-1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— 9 'G Ip SO SPECIFY A. OWNERS TANK ID p R. MANUFACTURED BY: v C. YEAR INSTALLED W D. TANK CAPACITY IN GALLONS: O I� 11. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED..COMPLETE ITEM D. O A. 1 MOTOR VEHICLE FUEL � 2 PETROLEUM B. C. 1 UNLEADED 0 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT 4 OIL `TPRODUCT ❑ 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.p C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A.TYPE OF ❑ 1 DOUBLE WALLED ❑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 CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE MATERIAL ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN Ej 99 OTHER C.INTERIOR ❑ I RUBBER UNED 2 ALKYDLINING 3 EPDXY LINING 0 4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D. CORROSION ❑ I POLYETHUENE WRAP ❑2 TAO 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 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 STEELCLAD W/FRP A U B 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. / S 1 VISUAL CHECK p W 2 INVENTORY RECONCILIATION P 3 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS Dlt�FS 6 PRECISION TESTING P 5 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 OUANTITY 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 B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION p AGENCY M FACILITY ID p TANK ID M © l� 0 / 6 7 a e o CURRENT LOCAL AGENCY FACILITY ID I E PHONE I WITH AREA CODE PERMIT NUMBER PERMITAP4;7 MIT EXPIRATION DATE 6 -//- o CHECK Y PERYIT AMOUNT SURCHARGE AMT. RECEIPT I BY:� FORM B(6-29-fie) THIS FORM MUST BE ACCOMPAI`rdY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS'PtURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY