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STATE OF CALIFORNIfS WATER RESOURCES CONTRO ARD FORM 'S': UNDE ROUND STORAGE TANK PRO AM f /AI TANK PERMIT APPLICATION INFORMATION TANK INFORMATION FOR EACH TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFO O O H MARK ONLY ❑ I NEWPERMIT ❑ 3 RENEWALPERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑A AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑'8 TANK REMOVED FACILITY/BITE NAME WHERE TANK IS INSTALLED: . ` - / - FARM TANK-YES❑ NO •0 I. TANKOESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDK `"7 B. MANUFACTURED BY: W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: ^Y d 11. TANK CONTENTS IF(A.1),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 ❑ A OIL ❑ 1PRODUCT ❑ #GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS El5 HAZARDOUS ❑ 80 EMPTY [:]95 UNKNOWN El2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED h C.A.S.K C.A.S.p: 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 WALLED ❑R SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑1 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑S CONCRETE ❑6 PDLYVIWLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ IB GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ C. INTERIOR I RUBBERLINED ❑2 ALKYDUNING ❑ 3 EPDXYLINING ❑1 PHENOLIC UNING ' LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH IW%METRANOL7 E]YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINT.WRAP ❑ /FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S 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 I 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 I SINGLE WALLED A U 2 COUPLE 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 H FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U B CONCRETE A' V 7 STEEL CLAOW/FRP A U R 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 ! I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P S 0 PRECISION TESTING P S 1 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 MATERIAL7 [:]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 A SIGNATURE) DATE L LOCAL AGENCY USE ONLY COUNTY# JURISDICTION K AGENCY K FACILITY ID K TANK IO# i CURRENT LOCAL AGENCY FACILITY ID/ APPROVED BY NAME PHONE I WITH AREA CODE 41 PERMIT NUMBER PERMIT APPROVAL DATE JPENMIT EXPIRATION DATE v ' CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT) BY. •,�-� FORM B(6.2mB) THIS FORM MUST BE ACCOMPANIED CILITY/SITE APPLICATION, FORM 'A',UNLESS A CU1q.rkT FORMA' HAS BEEN FILED I DATA PnnrccclMn nn•+.•