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STATE OF CALIFOR WATER RESOURCES CONT BOARD I FORM 'S': UN�GROUND STORAGE TANK PRiRAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ,a O MARK ONLY ❑ I NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] 7 PERMANENTLY CLOSED TANK ONE ITEM E] 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED Qq DO FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO A 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY —4 A. OWNERS TANK ID# 69w—ffAcl61 eul B. MANUFACTURED BY: UK' C.YEAR INSTALLED unL D. TANK CAPACITY IN GALLONS: Q 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. MOTOR VEHICLE FUEL 1] 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADEDY 3 CHEMICAL PRODUCT E] 4 OIL 1 PRODUCT ❑ 4 GASAHOL 5 JET FUEL E] 6 AVIATION GAS E]5 HAZARDOUS 80 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.&D A.TYPE OF ] 1 DOIIBLEWALLED F-1 3 SINGLEWALLED WITH EXTERIOR LINER 5 UNKNOWN SYSTEM 2 SINGLE WALLED 4 SECONDARYOONTAINMENT 99 OTHER 1 STEELIIRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCREFE 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM B 10094 METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL 5 UNKNOWN 99 OTHER 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING C. INTERIOR 5 GLASS LINING ❑ 6 UNLINED 5 UNKNOWN LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? E]YES El NO W OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP 2 TAR OR ASPHALT ❑ 3 VINYL WRAP 4 RBERGLASS REINFORCED PLASNC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONEUNKNOWN ❑ 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 9 UNKNOW 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 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM AU fiCONC A U 7 STEEL CLAD WYFRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UO95 KNOWN 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 S IVISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4ELE MONITOR P 5 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 954N P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MOYYR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COmNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FAC ITY ID# APP PHONE#WITH AREA CODE n maw PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29�8e) THIS FORM MUST BE ACCOMPANiTKY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS MRIENT FORMA' HAS BEEN FILED DATA PROCESSING COPY