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STATE OF CALIFORPW ' WATER RESOURCES CONT BOARD FORM 'S': UN GROUND STORAGE TANK PAGRAM TANK TANK PERMIT APPLICATION INFORMATION ?: ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 p MANENTLY-C o..K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE TANK REMO O FACILITY/SITE NAME WHERE TANK IS INSTALLED. �7 7 L'G, FARM TANK-Y I. TANK DESCRIPTION COMPLETE ALL MS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID N B. MANUFACTURED BY: C. YEAR INSTALLED 15 D. TANK CAPACITY IN GALLONS: IL TANK C TENTS I (A.1),IS MA D,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. CJ[ A 1 MOTOR VEHICLE FUEL LEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑4 OIL /IPRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 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&CA.S.N C.A.S.N: III. TANK CONSTRU ION MARK ONE ITEM ONLY IN BOX A,B,C,&D A.TYPE OF DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER E] 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1STEEUIRON ❑2 STAINLESS STEEL 3FIBERGLASS ❑4STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B MAITERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 16 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBERUNED ❑2 ALKYD LINING ❑ 3 EPDXY UNINGT❑�4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED L:CI KNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR ORASPHALT 3)VWCQV ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 114UNKNOWN ❑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 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 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 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 8 1 VISUALCHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MONA) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONSINERT MATERIAL? ❑yES ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N z CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(6-29-B6) THIS FORM MUST BE ACCOMPA IED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY