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STATE OF CALIF---'RNIA WATER RESOURCES 1NTROL BOARD ,�••:.��, ` FORM S% UNDERGROUND STORAGETA'k PROGRAM ` TANK TANK PERMIT APPLICATION INFORMATION ' COMPLETE A SEPARATE FORM WITH THE FOLLOWING)1 FORMATION FOR EACH TANK. ' MARK ONLY ❑I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TAN ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED i t J FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—80 SPECIFY t A. OWNERS TANK ID M O B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: L 11. 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 ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ i PRODUCT ❑4 ❑5 JET FUEL ❑8 AVIATION GAS Y ❑5 HAZARDOUS ❑80 EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) 1J 'r D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF s HAZARDOUS SUBSTANCE STORED&CA.S.N C.A.S.M: 3 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C.A D u A TYPE OF ❑ 1 E WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2 sl WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER i_ 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE F-16 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑e 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER t ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑ LINING C.INTERIOR 5 GLASS LINING ❑6 UNLINED NZ9 NOWN LINING ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? F1 YES El NO OTHER D.CORROSION F-1I POLYETHLENE WRM OR ASPHALT F-13 VINYL WRAP ❑4 RBERGtASS REINFORCED PLASTIC PROTECTION E]5 CATHODIC PROTECTION ff9l NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORM A N CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE AW SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHEF B.CONSTRUCTION A l`U2 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHEF t J A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 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. nP 1 VISUAL CHECK 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELL'. 1\ P 8 6 PRECISION TESTIN P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER +-' VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED TE LAST USED(MO/YR) 2.ESTIMAT QUANTITY OF 3.WAS NK FILLED WITH SUBST E EMAINING IN TERIAL? ❑YES ❑NC GALLONS THIS F RM HAS BEEN COMPLETED UNDER PENALTY F PERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT. APPUCANT'S NAME(PRINTED 6 SIGNATURE) DATE `J LOCAL AGENCY USE ONLY ECHECK 'TY JURISDICTION N AGENCY A FACILITY ID A TANK 10 A • A ENCY FACILITY 10 A APPR��Ti� IN r PHONE A WITH AREA CODE ' PERMIT APPROVAL DATE MIT EXP ON DATE PERMIT AMOUNT BURCHINGE AMT. FEE CODE RECEIPT• BY: " FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED si A FACILITY/SITE APPLICATION, FORM'A',UNLESS A',.dRRENT FORMA' HAS BEEN FILED -ATA nnnr%cea in/`ADV