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STATE OF CALIFORN! WATER RESOURCES CONTFO BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS K ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED S FACILITY/SITE NAME WHERE TANK IS INSTALLED: W 't-�_ FARM TANK-YES NO ❑ N I. TANKDESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID q B. MANUFACTURED BY: oK CO C.YEAR INSTALLED I -7 1 D. TANK CAPACITY IN GALLONS: Q O 11. TANK C TENTS 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 ❑4 UNLEADED LEADED El DIESEL 3 CHEMICAL PRODUCT 4 OIL I PRODUCT S E❑ ❑ 6 AVIATIONGAS ❑ 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 8 C.A.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER E]B.TANK 1 STEEL/IRON E] 2 STAINLESS STEEL E]3 FIBERGLASS ❑4 STEEL=WIFIBERGLASS REINFORCED PLASTIC MATERIAL. ❑ 5 CONCRETE ❑6 POLriINYL CHLORDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBERUNED ❑ 2 ALM LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS UNING ❑6 UNLINED ❑ 95 UNKNOWN ❑ IS UNING MATERML COMPATIBLE WITH 100%ME7HANOL7 YES ❑NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 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 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN ONS INERT MATERIAL? []YES ONO OALL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY �USE -TONLY COUNTY I® JURISDICTION � AGENCY N FACILITY ID Y TANK ID N o Ll I CURRENT LOCAL AGENCY F. ACID'ID 1 APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER W PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMIT AMOUNT .SURCHARGE AMT. FEE CODE ECEIPT I gy; IS, - Y PORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED BYAFACILITY/LTTE APPLICATION, FORM 'A',UNLESSACUflRENT FORMA' HAS BEEN FILED