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STATE OF CALIFORIV WATER RESOURCES CON-OL BOARD FORM 'S': UN ERGROUND STORAGE TANK PROGRAM -Nn . TANK TANK PERMIT APPLICATION INFORMATION ?io . COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. o r I MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO/SE�p TANK ONE ITEM ❑2 INTERIM PERMIT ❑i AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ANK REMOVEO V FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES F-1 NO ❑ 1- 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY C A. OWNERS TANK ID B B. MANUFACTURED BY: r C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,COMPLETE ITEM D. A. ❑ I MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ IPRODUCT ❑ 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS [:] BO EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.N C.A.S.It III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A TYPE OF ❑ I DOUBLE WAILED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT 99 OTHER ❑ I STEEUIRON 2 STAINLESS STEEL ❑3 FIBERGLASS 1 STEEL CLAD W)FIBERGLASS REINFORCED PLASTIC B.TK MATERIAL ❑5 CONCRETE ❑6 POLriINYI CHLORIDE ❑ 7 ALUMINUM ❑6 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2AU(YD LINING 3 EPDXY LINING d PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ I POLYETHENE WRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ❑ 1 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 I 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 I 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 I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U O 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. P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 1 3 VAGOSE WELLS P S < ELECTRONIC MONITOfl P / 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P 1 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH 1. H SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES F-� 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#—T'-' JURISDICTION m� AGE ❑ FACILITY IDN TANK ID N Ell�EU Z CURRENT LOCAL AGM APPROVED BY NAYE,i PM NE E WITH AREA CODE PERMIT NUMBERPERMIT APPROVAL DATE P MIT E% RAT( N DCHECKF SURCHARGE AMT. FEE CODE RECEIPT N BY. in FOBMB(6-29-60) THIS FORM MUST BE ACCOMPA IED BY A FACILITYISITE APPLICATION, FORM 'A',UNLE ACURRENT FORMA' HAS BEEN Pn Fn