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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN `t►NFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PE MANENTLY CLOSED 7A ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMOVED y FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑rNO 1 j #Q I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN/—SO SPECIFY A. OWNERS TANK ID# I B. MANUFACTURED BY: W ', C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),ISNOT MARKED, OMPLETE ITEM D. L9 i A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED E]2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 5 JE7 FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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 A CA.S.# CA.S.#: III. TANK CONSTRUC ON MARK ONE ITEM ONLY IN BOK A,B,C,AD A TYPE OF ❑1OOUBLF ❑3 SINGLE WALLED WITH EXTERIOR LINER L]95 UNKNOWN SYSTEM ❑2 SINGLE W ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEELIIRDN ❑2 STAINLESS STEEL F-13 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLAS$REINFORCED PLASTIC &TANK ❑ 5 MATERIAL CONCRETE E]6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑Z ALRYDUNING ❑3 EFOXYLINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING NJ 6 UNUNED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ I POLYETHLBIE WRAP ❑ 2OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 N E ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOV\EVROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 0IIESSURE 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 DO LE 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 STAT ESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE j C.MATERIAL A U 5 ALUMINUM A U S CONC E A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNO A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY, S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. PI I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VA SE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S S PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NO P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED I PLACE I 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED REMAINI 3.WASTMATERI MATERIAL? j SUBSTANCE QUAN INING WASINERT NK FILLED ❑yES ❑NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® I o = 101 (0 16121 CURREN):.FOCAL ITY ID APPROVED %NON k� Y/�/'j PHOME#WITH AREA CODE 01 PERMIT NUMBER PERMIT APPpOVAL DATE I I PERMIT EXPIRATION„DATE CHECK# PERMITAMOUNT _ SURC14ARGE AMT. FEE CODE RECEIPT# BV: FORMS(5-29-88) THIS FORM MUST BE ACCOMPAN Y o`,ILITY/SITE APPLICATION, FORM 'A UNLESS p FORMA' HAS BEEN FILED DATA PR:.'CLSSfia.^, r`^,Y,�.•