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STATE OF CALIFORNII WATER RESOURCES CONTROI ,OARD W FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION `m ,p COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT E]4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED / r FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7 S k le FARM TANK-YES❑ NO • 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID R a- B. MANUFACTURED BY: :too 9 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / S O 11. TANK C LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.11),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JEF FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 MEFHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.B C.A.S.F: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,&D A.TYPE OF 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER F-11 STEELARON ❑2 STAINLESS STEEL 3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALF-15 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ 1 RUBBOLINED ❑2 A LINING ❑ 3 EPDXYLINING E:]4 PHENDUC LINING LINING ❑5 GLASS UNING UNUNED ry/ [:]95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? u ES ❑ IO ❑99 OTHER 0.CORROSION ❑ I POLYEIHLENE WRAP ❑2 TARORASPHALT ❑3 VIWL WRAP ❑4 FIBERGLASS REINFORCED PLASM PROTECTION ❑ 5 CATHODIC PROTECTION 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 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A& FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM 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 5 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION TESTING 8 PRESSURETESTING P 8 91 NONE P 8 95 UNKNOWN P 8 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 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(POINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUN`T/YY# JURISDICTION# AGENCY* FACILITY RDW TANK IDVTE = = 101011 CURgEJ`NT LOCAL AGE Y FACILI IDM APPROVED BYNAME PHONE*WITH AREA CODE I r� 9 PERMIT NUMBER PERMIT APPROVAL DATE I I PEAWff EIDIRATION DATE CHECKx PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT* BY: FURM 6(62e 88) THIS FORM MUST BE ACCOMPANIBDd A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A,,,, ,RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY