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STATE OF CALIFORW WATER RESOURCES CONI.BOARD FORM 'S': UNIERGROUND STORAGE TANK PROGRAM `mom TANK TANK PERMIT APPLICATION INFORMATION .a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITCHANGE OF INFORMATION ❑7 PERMANENTLY CLO ANK ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED js FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5y6e) El AL&)q FARM TANK-YES❑ IN I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N S. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. 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 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL [gKPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS U 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF n HAZARDOUS SUBSTANCE STORED&C.A.S.# A C.A.S.#: ✓`j All. TANK CONSTRUCTION MARK ON ITEM ONLY IN BOX A,B,C,&D A TYPE OF 011-DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM M 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER 21, S1EELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR F-] 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 926 UNLINED ❑ 95 UNKNOWN ❑ ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP [:j 2 TAR OR ASPHALT ❑3 VINVLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION E] 5 CATHODIC PROTECTION E-]91 NONE 54'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 99 OTHER S.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C. MATERIAL A U S ALUMINUM A U B 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 . LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE- P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANJITY OF 3.WAS TANK LLED WITH SUBSTANC ING IN GALLONS I INERT �? ❑YES ❑ NO THIS FORM HAS EfEEN COMPLETED UNDER PENALTY OF PE JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# D v zZ ( D L) I t CURRENT LOCAL AGENCY FACILITY ID# APPR VED Y NA PHONE M WITH AREA CODE ! D Z � E BER PERMIT APPROVAL DATE PERMR EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTBY: FORMB(3-7-B8) THIS FORM MUST BE ACCOMPAI BYAFACILITY/SITE APPLICATION, FORM `A',UNLE URRENT FORMA' HASBEENFILED DATA PROCESSING COPY