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STATE OF CALIFORNIA WATER RESOURCES CONTRO#OARD °:.'; FORM 'S': UND ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION �.m COMPLETE ASEPARATE FORM WITH THE FOLLOWING,INFORMATION FOR EACH TANK. MARK ONLY PERMIT 3 RENEWALPERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CL ONE ITEM INTERIM PERMIT .�4 AMENDED PERMIT [—]6 TEMPORARY TANK CLOSURE �B TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: Z FARM TANK-YES❑ NO O I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID R R. MANUFACTURED BY: Cl3 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: " II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. C J A. ❑ 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ELC. 1 UNLEADED E]2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT- E]4 OIL ❑ I PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS ❑80 EMPTY [:j 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.R C.A.S.W 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&D A TYPE OF ❑ I DOUBLE WALLED F-�3 SINGLE WALLED WITH EXTERIOR LINER %UNKNOWN SYSTEM ❑2 SINGLE WALLED 4 SECONDARY CONTAINMENT %OTHER ❑ I STEEL/IRON 2 STAINLESS STEEL ❑3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS RUNFORCED PLASTIC B.TANK YMATERIALF-15 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP 9 BRONZE 10 GALVANIZED STEEL %UNKNOWN %OTHER C. INTERIOR XYO I RABERUNFD 2 AILINING F-13 EPDXYUNING ❑4 PHENOLICUNING LINING ❑5 GLASS LINING fi UNLINED [:]95 UNKNOWN E]IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑NO ❑ 99 OTHEI D.CORROSION ❑I POLYERUNE WRAP [:]2 TNR OR ASPHALT F-1 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE ❑%UNKNOWN %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 .0 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 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 8 10D%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 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 5 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 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 QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONB INERT MATERIAL? —]YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY J COUNTY Y JURISDICTION Y AGENCY P FACILITY ID 8 TANK ID Y 3M = = I o1 Doo CURRENT LOCAL AOENCIY FACILITY ID 8 APPROVED BY NAME PHONE 8 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE I PERMIT EXPIRATION DATE cl CHECK PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT• BY: ! �� ti FORM B(6 29-99) THIS FORM MUST BE ACCOMPANIE oY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A 1,L,3RENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY