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STATE OF CALIFORK. WATER RESOURCES CONTR. BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING 1NFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C NK ONE ITEM El2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ANK REMOVE �/ �r0�L W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1C1IL NOM T2- FARM TANK-YES NO ❑ FV 0 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (Q A. OWNERS TANK IDa B. MANUFACTURED BY: co C. YEAR INSTALLED U4 1 D. TANK CAPACITY IN GALLONS: 9-0 Q V It. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑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) O. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.a C.A.S.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.E D A TYPE OF ❑ I DOABLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNEP 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEELMRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MMATERIALEl5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10L1%METHANOLCOMPATIBLEFRP - ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBEHUNED ❑ 2 ALXYD LINING F-13 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑fi UNLINED ❑ 95 UNKNOWN IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POIYETHLFNEWR4P ❑ 2 TAR On ASPHALT ❑3 VINYL 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 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/RON 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/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. B 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P f 5 GROUND WATER MONITORING WELLS P f 6 PRECISION TESTING P f 7 PRESSURE TESTING P B 91 NONE P 8 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OFGALLONS 3. WAS TANK FILLED WITH 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 COUNTY B JURISDICTION M AGENCY B FACILITY ID B TANK ID B vv CURRENT LOCAL AGENCY FACL ID• '/ APPROVED BYNAME PHONE B WITH AREA CODE ZN7G/ aV PERMIT NUMBER PERMIT APPROVAL DATE PERYIT EXPIRATION DATE G�j CHECK I PERMIT AMOUNT I SURCHARGE AMT. FEE CODE "-CEIPT A BY: FORM B(6-2o-ff®) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED � Horn nonrmmur rnov