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STATE OF CALIFORK,,6 WATER RESOURCES CONTF,._.. BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM a /+/ TANK PERMIT APPLICATION INFORMATION y� TANK' ^e K�'` COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z' ET 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS NK ONE ITEM >- ❑ 2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED a' FACILITY/SITE NAME WHERE TANK 18 INSTALLED: "-7,-V FARM TANK•YES NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY un A. OWNERS TANK ID p L- I S. MANUFACTURED BY: r-0 C.YEAR INSTALL D. TANK CAPACITY IN GALLONS: II. TANK C94TENTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A.1).IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. F] 1 UNLEADEDEZ3-1-LEADED ❑ 3 DIESEL B. ❑3 CHEMICAL PRODUCT ❑ A OIL RODUCT ❑ 4 GASAHOL ❑ 5 JET 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&C.A.S.M C.A.S.R: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B.C.A D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLE WAILED ❑ 1 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ t STEELIIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLOWDE ❑ 7 ALUMINUM ❑B 1006 METHANOL COMPATIBLE FRP MATERIAL. :; ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 )RUBBER UNED ❑2&M LINING ❑3 EPDXY LINING ❑1 PHENOLIC LINING G INTERIORIG ❑ 5 CLASS LINING ❑6 UNUNED ❑95 UNKNOWN ❑ ISUNINGMAMMLCOIAPATIOUMTHIOD%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETMLFNE WRAP ❑ 2 TARORASPHALT ❑3 VIMLWRAP ❑A FIBERGLASS REINFORCED PLASTIC PROTECTION: ❑ 5 GTHODK: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 STEEUIRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U K FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CI-ADW/FRP A U 8 1O0 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. LPP 8 1 VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 8 6 PRECISION TESTING P 6 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 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 OALLONB INERT MATERIAL? ❑YES E] 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 Y - JURISDICTION B AGENCY B FACILITY ID B TANK ID B CURRENT LOCAL AGENCY FACILITY ID F / APPROVED BY NAME PHONE I WITH AREA CODE 6 A PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT I BY: j,1A1 Rf FORM B(s-29-se) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED