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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM aim TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z TANK O MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED a, N / FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 4111OD 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDV B. MANUFACTURED BY� / w D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED ..1 II! II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ffl MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL Uk I I 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) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.B: HAZARDOUS SUBSTANCE STORED&C.A.S.K A/ I Al 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX 0.B,C.8 D A TYPE OF 1 DOUBLE WALED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEELIIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 04 STEEL CLAD WIFIBERGU;$REINFORCED PLASTIC B.TANKF-1 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM F-] 0 100%MEfHANOL COMPATIBLE FHP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER ❑ 1 RUBBERUNED ❑2 ALMUNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C LININGRRIR ❑5 GLASS LINING Vr6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWRAP j 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A VUJ/ 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 (612 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 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC) A FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. �). P S1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELL 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS D P S 6 PRECISION TESTING P 5 7 PRESSURE TESTING P 8 91 NONE P B 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DAE LAST USED(MO/YR) 2. ESTIMATED O ANTITY OF 3.WAS TA K ILLED WITH AZ IA I SUBSTAN AINING IN INERT IAL? ❑YES ❑ NO GALLONS 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 N JURISDICTION M AGENCY N FACILITY ID# TANK ID# DR] QZ] I o ) 10 16 CURRENT LOCAL AGENCY AGILITY ID k APPROVED BY N ME PHONE#WITH AREA CODE iv I PERMIT NUMBER PERMIT APPROVATE PERMIT EXPIRATION DATE / CHECK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMB(6-29-88) THIS FORM MUST BE ACOOMPA41Z BY A FACILITY/SITE APPLICATION, FORMIA',UNLE ..URRENT FORMA HASBEENFILED DATA PROCESSING COPY