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STATE OF CALIFOW.A WATER RESOURCES CONT"OL 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 PERMIT5 CHANGE OF INFORMATION 7 PEflMANENTLY CLOSED TANK 1 V ONE ITEM ©p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE S TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: 32W - 2� FARM TANK-YES❑ NO (may I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID p Co B. MANUFACTURED BY: TV C. YEAR INSTALLED D, TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED D 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OILEl E]6 AVIATION GAS I Pfl000CT 1 GASAHOL 5 JET FUEL 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN E]2 WASTE O 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.N C.A.S.p: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED F]3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM E]2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER TANK I STEEL/IRON 2 STAINLESS STEEL 0 3 FIBERGLASS 4 STEEL CLAD WYHBERGtASS REINFORCED PLASTIC B MATERIAL 5CNICRETE ❑6 POLYVINYL CHLORIDE E] 7ALUMINUM B IDDIIMETHANOLCOMPATIBLEFRP 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN E]99 OTHER C. INTERIOR 0 RUBBER LINED 2ALKYD LINING ❑ 3EPDXY LINING 4PHENOUCLINING LINING ❑ 5 GLASS UNING 6 UNLINED 95 UNKNOWN m IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? E]YES E] NO 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT [:] 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION 91 NONE E]95 UNKNOWN 0 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSUHE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.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 I STEELPRON 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 CLADW/FRP A U B ID 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 I VISUAL CHECK P S 2 INVENTORY HECONCILIA110N P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WAIEH MONITORING WELLS P S 6 PRECISION TESTING P S 1 PRESSURE TESTING P S 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 ALLONS INERT MATERIAL? E]YES E] NO G 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 COUNTY p JURISDICTION B AGENCY# FACILITY ID N TANK ID N CURRENT LOCAL,AGENCY FACILITY ID 11 APPROVED BY NAME PHONE p WITH AREA CODE PERMIT XUYBER PERMIT APPROVAL DATE PlERMFf EXPIRATIO ATE CHECK6 PERMITAMOUNT RCHARGE AMT. FEE CODE �1PTI BY: FORM B(6.29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION. Fn R AA '4' uMl ccc a rnoucuT rnn.. .• ... .,��..�..�..