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STATE OF CALIFORN& WATER RESOURCES CONTR�BOARD FORM 'S': UNDERGROUND STORAGE TANK PR RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT HANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT P716 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED / FACILITY/SITE NAME WHERE TANK IS INSTALLED: T-757f2 G - 1° FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# B. MANUFACTURED BY: e C.YEAR INSTALLED 17D. TANK CAPACITY IN GALLONS: w 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. P A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT [ja'4 OIL ❑ t PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ©2 WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) CLE FUEL,ENTER NAME O. IF NOT MOTOR HAZARDOUS SUBSTANCE STORED&C.A.S.#OF OTM S),e L9, / CAS # 05 XIII. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM EaISINGLEWAILED ❑4 SECONDAHY CONTAINMENT ❑99 OTHER STEBUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE F-17 ALUMINUM E]B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑5 GLASS LINING Fg4lUNUNED ❑ 95 UNKNOWN ❑ISUNING MATERIAL COMPATIBLE WITH t00%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑��1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP [-]4 RBERGLVS9 REINFORCED PLASTIC PROTECTION LJ✓ S CATHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A oo 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH Ao 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 C. MATERIAL A U 5 ALUMINUM A LJ_8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8190%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 5 UNKNOWN A U 99 OTHER A� Y. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. \V P S 1VISUAL CHECK S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 6 PRECISION TESTIN 8 7 PRESSURE TE STING P 9/ NONE P 8 95 UNKNOWN P S 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 ;REMAINING IN GALLONS INERT MATERIAL? ❑ YES E] 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# JURISDICTION# AGENCY# FACILITY IO# TANK ID# [m I od / aa / CURRENT LOCAL AGENCY FgCILITY IDN APPROVED BY Ngo, PHONE X WITH AREA CODE $ gF� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE F7CKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT0 BY: FORMB(3-7-88) THIS FORM MUST BE ACCOMPANIt dYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS IrURRENT FORMA' HASBEENFILED DATA PROCESSING COPY