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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDEh%wROUND STORAGE TANK PROL.�AM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED TANK 1 ONE ITEM F-] 2 INTERIM PERMIT ❑4 AMENDEDPERMIT El6 TEMPORARY TANK CLOSURE TANK REMOVED a / FACILITY/SITE NAME WHERE TANK IS INSTALLED: S; XLL ('„ FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY -4 CTI A OWNERS TANK IDN B. MANUFACTURED 8Y: � C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: If. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED OMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL [�r'1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 60 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.M CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,A D A TYPE OF ❑ 1 DOUBLEWAIlED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑ 95 UNKNOWN SYSTEM V2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 SfEEUIRON ❑2STAINLESS STEEL ❑ 3FIBERGLASS ❑4STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVIWL CHLORIDE ❑ 1 ALUMINUM ❑B 109%METHANOLCOMPATISLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑ 2 ALM UNING ❑3 EPDXY LINING ❑4 PHENOLIC UMNG LINING ❑ 5 GLASS LINING ❑ 6 UNUNED ❑ 95 UNPWN ❑ ISUNING MATERULCOWATIBLENTH 190%MEDIANGL7 ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYERHLENEWNPP ❑2 TAR OR ASPHALT ❑ 3'AWL WRAP ❑ 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 U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 8.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 U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U B 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 6 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED GUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INGALLONS 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY IDN TANK ID N EHI 1 .1 1 / = I-�) I v L CURRENT LOCAL AGENCY FACILITY IDI APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EIVIRATION DATE 'S CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: z FORMB(6-29-66) THIS FORM MUST BE ACCOMPANIL"A FACILITYISITE APPLICATION, FORM 'A',UNLESS A�4ENT FORMA' HAS BEEN FILED .',. DATA PROCESSING COPY /-Gi?