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STATE OF CALIFORN19 WATER RESOURCES CONTRIISOARD , FORM 'S': L UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION � ° ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Z ;o MARK ONLY . '-❑ I NEW PERMIT ❑3 RENEWAL PERMIT �/ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSEDT�K ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED /S l CA FACILITY/SITE NAME WHERE TANK IS INSTALLED: TCF FARM TANK-YES 2 NO ❑ fV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY CA 9' 3�� co A OWNERS TANK ID F _ B. 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 ❑ 3 DIESEL ❑3 CHEMICALPROWCT ❑1 OILF-11 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY �5 UNKNOWN E]2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.F C.A.S.S: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B.C.B D A TYPE OF ❑ I OOUBLEWALIED ❑3 SINGLE WALLED NTH EXTERIOR UNER ❑95 UNKNOWN SYSTEM. ❑ 2 SINGLE WALLED ❑1 SECONDARYCONTAIWENT ❑99 OTHER ❑ 1 STEWRON ❑ 2 STNNLESSSTEEL ❑3 RBERGLA55 ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 MOIETE ❑6 POLYVRMO0RIDE ❑7 ALUMINUM ❑B 1808 UMMOLCOMPATIBLE FRP MATERIAL..:: ❑9 BRONZE ❑ 16 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR I RUBBBILIED ❑2 AIAYDUNING ❑3 EPDXY LINING ❑1 PHENOLIC LINING LINING ❑5.GLASSLYBNO ❑6 UNLINED ❑95 UNKNOWN ❑ Is!MING MATERIAL COMPATIBLE WITH IOD%METHANOL? [:]YES ❑ NO ❑ 99 OTHER 0.CORROSION ❑ I POLYEDUBXWRAP ❑2TAR OR ASPHALT ❑3 VINYL WRAP ❑1 FIBERGLASSREINFORCEDPLASTIC PROTECTION ❑5 GIHODIC PROTECTION ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVE 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 I, A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 6 10)%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 RECONCIUATION P S 3 VADOSE WELLS P S R ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS P S S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 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. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION 8 AGENCY 8 FACILITY ID 8 TANK ID 8 CURRENT LOCAL AGENCY FACILITY ID S APPROVED BY NAME PHONE t WITH AREA CODE PERMITNUMBER PERMIT APPROVAL BATE PERMIT EXPIRATION DATE CHECKS PERMIT AMOUNT URCHARGE AMT. FEE CODE •CEIPT 0 fly: 1,1)12 • ,,,.,.ww........�..e.wA....w.I.—e,.. e.w„,....m.v.nm m,vnu Cl1GSA 'A� Iimeee.nmoeut enou•r u.e ueeu nl cn /