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STATE OPCALIFORNI0 WATER RESOURCES CONTRARIOARD r, FORM 'S'. UNDERGROUND STORAGE TANK PROGRAM TANK �`Z, TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z MARK ONLY ❑I NEW PERMIT " ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P ANENTLYDT K ONE ITEM - ❑2 INTERIM PERMIT _ ❑I AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE B TANK REMOVE G�' CrJ FACILITY/SITE NAME WHERE TANK IS INSTALLED: 773-1 77Yj7 //1 �T FARM�TAN�K�-YES NO ❑ (� I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY C1J jZf E7 A OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED (Ifl I D. TANK CAPACITY IN GALLONS: /006 IL TANK CONTENTS NTENTS IF(A.1),18 MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE C. ❑ ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. 1 UNLEADED 2 LEADED ❑ 3 DIESEL U ❑3 CHEMICALPRODUCT ❑ /OIL 1 PRODUCT ❑1 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY [:]95 NKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C,iD A TYPE OF ❑ I DOUBLE WALD ❑3 SINGLE WALLED NTH MEW LINER ❑95 UNKNOWN SYSTEM. ❑2 SINGLE WALLED ❑X SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 ST UIRDN ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑X STEEL CUD WIFIBERGLAS9 REINFORCED PLASTIC B.TANK ❑5 CONO m ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑N 100%METHANOL COMPATIBLE FRP MATERIAL. ❑9 SNONZE ❑10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ G INTERIOR 1 RIBBER UNE ❑2 ALKYD UNNG ❑3 EPDXY UNING ❑A PHENOLIC UNING LINING ❑5 GLASS UIBNG ❑6 UNLINED ❑95 UNKNOWN ❑ISUMNGwie6N.COMPATIUENTH Iro%MEtIwaL1 ❑YES ❑No ❑99 OTHER FDCROOTROSION ❑1 POLYE09ENEWRAP ❑2 TAR OII ASPHALT 3 WNrtwRAP ❑X FlBERG ASS REIMORCEO FUSTIC ECTIO ❑ 5 CATHODIC PROTECTION ❑91 NOIR ❑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 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVIFIYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL CLAD W/FRP A U S 1GDW 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 # 1 VISUAL CHECK P # 2 INVENTORY RECONCILIATION P A 3 VADOSE WELLS P B I ELECTRONIC MONITOR P 9 5 GROUND WATER MONITORING WELLS P # B PRECISION TESTING P # 7 PRESSURE TESTING P # 91 NONE P B 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED OUANTRY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES El NO GALLOWS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANTB NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY# FACILITY ID N TANK ID# = = CURRENT LOCAL AGENCY FACILITYID N APPROVED BY NAME PHONE F WITH AREA CODE 1 .1 -7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE -7 --s?1 17CK N PERMIT AMOUNT RCHARGE AMT. FEECODE IPTF BY: `J /✓�� •~•, FORMB(e-2"8) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED