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STATE OF CALIFORN- 1 WATER RESOURCES CONTF BOARD FORM 'S': UNDERGROUND STORAGE TANK PR$GRAM TANK TANK PERMIT APPLICATION INFORMATION QO COMPLETE A SEPARATE FORM WITH THE FOLLOWING I RMATION FOR EACH TANK.MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 10 ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED TANK ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED p9 FACILITY/SITE NAME WHERE TANK IS INSTALLED: S 3 f FARM TANK-VES❑ NO W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W CI1 A. STAID YEARINSTALLED B. MANUFACTURED BY: (.11 C. YEAR NSTALLL ED /4 7 y D. TANK CAPACITY IN GALLONS: S 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 ROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT 4 OIL ❑ 1 PR CT ❑4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN WASTE ❑ 7 METHANOL THER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.M le moi/ C.A.S.Y: + .S III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGUSS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBERUNED 2 LINING El EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS UNING 6 UNLINED R:UINOWN N ❑IS UNING MATERIAL COMPATIBLE WITH 10D%METHANOL? ❑YES [D YES OTHER F ORROSION ❑ I POLYETHLENE WRAP ❑ 2 OR ASPHALT 3 VINYLWRAP 4 FIBERGLASS REINFORCED PLASTIC OTECTION ❑ 5 CATHODIC PROTECTION91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A' )GRAVITY A U 91 NONE A U 95 UNKNOWN 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 U 95 UNKNOWN A U 99 OTHER A{�"U/�7 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 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 S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VAOOSE WELLS P S 4 ELECTRONIC MONITOR P 3 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 995 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YH) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY B JURISDICTION K AGENCY B FACILITY ID R (y TANK IO N /`} CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK F PERMIT AMOUNT SURCHARGE AYT. FEE CODE RECEIPT-F BY: I FoRMe(6-29-88) THIS FORM MUST BE ACCOMPAIIRE'BY A FACILITYISITE APPLICATION, FORM 'A',UNLESSACURRENT FORMA' HASBEENFILED DATA PROCESSING COPY