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STATE OF CALIFORNC WATER RESOURCES CONTR( 30ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM =m ` TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z 10 MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL05WJANK ONE ITEM ❑2 INTERIM PERMIT 714 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q I � � FACILITY/SITE NAME WHERE TANK 18INSTALLED: b . FARM TANK-YE8❑ NO Eff IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY N A. OWNERS TANK ID# Q B. MANUFACTURED BY: a4'.*1 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,COMPLET TEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑�OLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ 1 PRO UCT ❑ 4 GASAHOL ❑5 JET F L ❑ 6 AVIATION GAS © 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN WASTE ❑ 7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF SUBSTANCE STORED&C.A.S.# C.A.S.# Ar— HAZARDOUS III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A TYPE OF Ulpwkli WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ 81W%METHANOLCOMPATIBLEFRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBERUNED ❑2 UNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑ 5 GLASS LINING 6 UNLINED ❑95 U NOWN//A� ' E] ISUNING MATERIAL COMPATIBLE WITH 100%MEMNOL? ❑YES F] NO 99 OTHER 6"� D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 V WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A(6)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 9/ NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. 1�- ; VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 6 PRECISION TESTIN P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER V . INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMAT DATE UST USED(MO/YR) 2.ESTIMATED DUNTITY OF 3.WAS TANKILLED WITH SUBSTAE M/6K( GALLONS NING IN INE M L? ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# lo (> 1 DD 1013 CURRENT LOCAAGENCY FA IUTY ID# APPROVED BY NA PHONE#WITH AREA CODE c C PERMM NUMBER PERMIT OVAL DATE PiRMIT EXPIRATION DATE / 6/75 CHECK# PERMIT AMOUNT SURCHARGE AMT.f FEE CODE RECEIPT# BY: FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIETi dY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AAMRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY