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STATE OF CALIFORN1WATER RESOURCES CONTROL BOARD FORM 'S': UNDE ROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION .� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑1 NEW PERMIT 3 RENEWAL PERMIT 1�r5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: C p/i S 7 -013 C FARM TANK-YES❑ NO 1 O iI. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID RLp B. MANUFACTURED BY: C. YEAR INSTALLED / 6 D. TANK CAPACITY IN GALLONS: /"d 0 0 0 II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(0.1),IS NOT MARKED,COMPLETE ITEM D. it OS A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 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 8 CA.S.8 C.A.S.p: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A.TYPE OF ❑1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER ❑ 1ST WIRON ❑ 2 STAINLESS STEEL Co3 FIBERGLASS ❑4 STEEL CLAD WIRBBIGLASS REINFORCED PLASTIC S. TANK ❑5 CONCRETE ❑B POLYVINYLCHLORIDE F-17 ALUMINUM F-]B 1011%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYO UNING ❑3 EPDXY UNING ❑4 PHENOUC LINING C LINING INTERIOR ❑5 GLASS LINING 6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATETRIALCOMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TARORASPHALT ❑3 VINYL WRAP ®4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPROTECTON ❑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 1 SUCTIONA PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A Q4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD 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. 8 VISUAL CHECK P S INVENTORY RECONCILIATION P S 3 VACOSE WELLS (0S a ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 6 1 PRESSURE TESTING P S 91 NONE P 5 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 OALLONB INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN O BESTeOF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) ill DATE G. T MEYER-U.G.T. ANALYS P- LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILIVY IDN TANK ID k 1111T= 1 I HLFCURRENTOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY: FORM B(3 7-66) THIS FORM MUST BE ACCOMPAMBY A FACILITY/SITE APPLICATION, FORM *A',UNLESWURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY