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STATE OF CALIFORF* WATER RESOURGES,CONTI•. BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1 FORMATION FOR EACH TANK. 1 NEW PERMIT 3 RENEWAL PERMIT ✓ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK I C MARK ONLY ❑ ❑ ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED L'9 FACILITY/SITE NAME WHERE?ANK IS INSTALLED: 7 Fa `� Cr , /7�, G/iJ FARM TANK-YES NO � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CT A. OWNERS TANK ID q 71 B. MANUFACTURED BN G14 . �- CA C. YEAR INSTALLED L D. TANK CAPACITY IN GALLONS ,� j 1�� 11. TANK CONTENTS IF IA.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑1 OIL I PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL 6 AVIATION GAS ❑ 5 HAZARDOUS ❑BO 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 6 C.A.S.N l/(:� C.A.S.n� III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D 1 BIF WALLED 3 SINGLE WALLED WITH WEROR LINER E]95 UNKNOWN A TYPE OF ❑ SYSTEMSINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER TANK - I STEEUIRON Ej 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] B IBD%METHANOL COMPATIBLE FRP / ❑9 BRONZE ❑ IB GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PH IC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED 5 UNKNOWN ❑IS LINING MATERIAL.COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 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 A13OVE 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 U 95 UNKNOW A U 99 OTHER B. CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN 99 OTHER A\'$ 1 STEEL/IRO A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIB S PIPE A U 91 NONE C.MATERIAL A Tl-S-ALTI INUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%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 6 1 VISUAL CHECK P 5 2 INVENTORY RECONCILIATION P 3 9 YADOSF W >LLS P S 4 ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING S 91 YQAIE/ p S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED IMO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TA NK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? El YES � NO G(LLONS 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 ONLY COUNTY Y JURISDICTION# AGENCY q FACILITY ID N TANK ID# 7 `/ CURRENT LOCAL AGENCY FACILITY Ip F APPROVED BY NAPE PRONE 0 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK q PERMIT AMOUNT SU ARGE AMT. FEE CODE RECF' '4 BY:�7 FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' NAS BEEN FILED A V