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STATE OF CALIFORIV WATER RESOURCES CONT BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. e MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 0-5'6HANGE OF INFORMATION 7 PERMANENTLY CL OSE ONE ITEM E]2 INTERIM PERMIT E] 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED �`j J FACILITY/BITE NAME WHERE TANK IS INSTALLED: �' �- , (,L:'�- �,y/�.,�- P FARM TANK-YES❑ - rr I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY 4 A. OWNERS TANK ID I ) B. MANUFACTURED BY: C. C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: , CCC-L c�c� IL TANK C TENTS IF IA.1),IS MARKED,COMPLETE ITEM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A. al MOTOR VEHICLE FUEL ❑2 PETROLEUMD. C. L] 1 UNLEADED E:]2 LEADED DIDIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑1 PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑ B AVIATION GAS ❑ 5 HAZARDOUS ❑80 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 A C.A.S.N C.A.S.W III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,8 D A TYPE OF ❑ I U Wim ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM L 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK MATERIAL F-15 CONIXIETE ❑B POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑6100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-1I RUSBERLNED ❑2 ALINO'LINING ❑3 EPDXYLINING ❑4 PHENOLICUNING LINING ❑5 GLASS LINING E-96 UM1NE0 ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATI&E WITH _IOD/%METHANOL? ❑YES [—]NO E]99 OTHER D.CORROSION ❑ I POLYETHILNE WRAP E]t)w11 OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑9S UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTIQN..__ A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A IIS 95 UNKNOWN 'A U 99 OTHER B.CONSTRUCTION A 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 I STEEL/IRON, A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U-5-ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/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 1VISUALCHECK P 6 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P B 4 ELECTRONIC MONITOR P B S GROUND WAI ER MONITORING WELLS P S B PRECISION TESTING P S 7 PRESSURE TESTING 0 S 91 NONE—, P 6 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? VES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION I AGENCY I FACILITY ID I TANK ID I CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME PHONE 4 WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK/ PERMIT AMOUNT SURCHARGE AMT. FEE CODE PTA BY: '7 FORM B(6-29e8) THIS FORM MUST BE ACCOMPANIED FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY