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STATE OF CALIFOR�' WATER RESOURCES CONTF BOARD FORM 'S': /3 UNDERGROUND STORAGE TANK PROGRAM TANK Cf TANK PERMIT APPLICATION INFORMATION Go COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK I C) ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED of FACILITY/SITE NAME WHERE TANK IS INSTALLED: /�� t' � FARM TANK-YESEZJ. O ❑ Cwt) 1. TANK DESCRIPTIONCOMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Lrl A. OWNERS TANK IDN B. MANUFACTURED BY: F-a C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ I UNLEADED ❑ 2 LEADED SEL B. ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.p CA.S.p: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN 801(A,B,C,A D A TYPE OF ❑ 1 qwBEE WANED ❑3 SINGLE WALLED WNH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 5~CONTAINMENT ❑99 OTHER ❑ 1 STFEUIRDN 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑5 CONCRETEF-16 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ S 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED$JFEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER UNED ❑ 2 WING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING UNUNED ❑ 95 UNKNOWN ❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POIYETHLENE WRAP [3 2 TAR OR ASPHALT ❑3 WRAP E]4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICRIOTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 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 &-%j-UNKPjQWD A U 99 OTHER A U I STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5ALUMINUM AU B A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A UNKNO N A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR 8 FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S t VISUAL CHECK P 5 2 INVENTORY RECONCIUATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION p AGENCY p FACILITY ID N TANK ID p CURREI�IIIOCALALL AC ENCY FACILITY 100 APPROVED BY NAME PHONE L WITH AREA CODE \ PERMIT NU''M�mn 77lG' PERMIT APPROVAL DATE PERMIT EMRATION DATE " \ CHECK 4 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT E \\\VVVNNN '-' s/r FORM B(6-29-M) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNL CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY