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STATE OF CALIFONIA WATER RESOURCES C � TROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED C'/ FACILITY/SITE NAME WHERE TANK 18 INSTALLED: 3 f_ FARM TANK-YES❑ NO c ' r I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDMf 7 B. MANUFACTURED BY: �`lC C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: , II. 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 LEADED ❑3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL ❑a1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑60 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&C.A.S.I C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D A.TYPE OF ❑ 1 LE WEE ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM SINGLE WALLED ❑/SECONDARY CONTAINMENT ❑99 OTHER STEEL/IRON E]2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B MATERIAL ❑5 CONCRETE ❑S POLYVINYL CHLORIDE ❑ i ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL E].95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY LINING ❑/PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNUNED ❑-9SUNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 1 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑'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 AU 91 NONE A U 9 NKN 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 UNKNOWNS U 99 OTHER A U ISTEEL/IRON A U 2 STAINLESS S1 EEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 0 CONCRETE A U I STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 OALVANIZED STEEL A 95 UNKNO 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 B 1 VISUAL CHECK P O 2 INVENTORY RECONCILIATION P B 3 VADOSE WELLS P B I ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P / 6 PRECISION TESTING P B 7 PRESSURE TESTING P B 91 NONE P B 11N R�VN- P K 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USED(MO/YR) 7SIISMIAT EDQUANTITY OF 3WAS TANK FILLED WITH UBANCE REMAINING IN GALLONS INERT MATERIAL? F-1YES [:] 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 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY I JURISDICTION 0 AGENCY N FACILITY ID M TANK ID N L7 c � I I -I 1 -1 L I T-1 I d f) I ,/ I v I =c) I 77FT-1 CURRENT LOCAL AGENCY FACILITY ID 1 APPROVED BY NAME / PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAT! PERMIT EXPIRATION DAT! CHECK I PERMIT AMOUNT SURCHARGE AYi. FEE CODE RECEIPT/ BY: I OIIM B(tt-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED