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S I A I It UP CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDE6 .AOUND STORAGE TANK PROL..,AM TANK ITANK 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 ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK CLOSURE 198 TANK REMOVED 1001 FACILITY/SITE NAME WHERE TANK IS INSTALLED: n , ©s' �„ /�/ C a FARM TANK-YES❑ NO N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY --4 CTI A OWNERS TANK ION B. MANUFACTURED BY: 07 C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 0 II. TAN CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A,1),IS NOT MARKED, OMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Eo/i PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.8 C.A.S.8: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SOX A,S.C.&D I WALLED F-13 SINGLE WALL®WITH E%TFANNI LINER ❑%UNKNOWN A TYPE OF ❑ SYSTEM LJ6 2 SINGLE WALLS) ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/F18ERGLASS REINFORCED PLASTIC S.TANK ❑5 CONCRETE ❑ B POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B tW%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑%OTHER C.INTERIOR ❑ I RUBBERUNED ❑2 ALKYDUNING ❑3 EPOKY'UMNG ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED ❑ 95 UNI(NaWN ❑ S UNING MATERIAL COMPATIBLE WITH 108%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ 1 P%YETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 AWL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION E:] 91 NONE ❑95 UNKNOWN ❑%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 IL 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 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 CLAD W/FAP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZEDSTEEL 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 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 8 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P B 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 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION 8 AGENCY B FACILITY ID A TANK ID M CURRENT LOCAL AGENCY FACILITY 10♦ APPROVED BY NAME PHONE 1 WITH AREA CODE PERMIT NUMBER PERMR APPIIOVAL DATE PERMIT EXPIRATION DATE i> CHECKS PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT/ BY: C FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE,..,A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A�iENT FORMA' HAS BEEN�1 DATA PROCESSING COPY