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STATE OF CALIFORNIAWATER - ..... .._ . ... RESOURCES CONTR ARD FORM 'S': UNDERGROUND STORAGE TANK PROMAM ��- j TANK TANK PERMIT APPLICATION I ORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING FORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PER c„ .. 1I p ONE ITEM 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANW 2 INTERIM PERMIT q AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED !�- FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFUNKNOWN—SO FARM TANK-YES NO ❑ F-• SO SPECIFY 00A. OWNERS TANK IDM � B. MANUFACTURED BY: 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 ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL FE:12 C. ❑ I UNLEADED ❑2 LEADED ❑3 DIESEL ❑ ❑80 EMPTY 95 UNKNOWNRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS ASTE ❑ 7 METHANOL ❑g9 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.M 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D C A.S N. A.TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM E]2 SINGLE WALLED 5 UNKNOWN ❑4 SECONDARY CONTAINMENT ❑99 OTHER B. TANK ❑ I STEEL/IRON ❑2 STAINLESS STEEL 0 3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE 0 7 ALUMINUM ❑ 9 BRONZE 10 GALVANIZED STEEL ^�UNKNOWN 99 OTHERETHANOL COMPATIBLE FRP ❑ Lam' C. INTERIOR ❑ 1 RUBBER LINED ❑2ALKY0 LINING L❑J„"3��EPDXY LINING ❑5 GLASS LINING E]4 PHENOLIC LINING LINING ❑6 UNLINED �NKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL7 ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL---------------------- _jRA PROTECTION ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ 5 CATHODIC PROTECTION ❑g1 ONE ❑-85'ONKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVEGROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 sucrloN a u 2 PREssuRE INGLE WALLED A A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 S U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER 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 A U 5 ALUMINUM A6 CONCRETE A U 9 GALVANIZED STEEL A�1 95 UNKNOWN A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP 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 I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLSS 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS INERT MATERIAL? ❑YEB ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION N `---� AGENCY N FACILITY ID R TANK ID M C) CURRENT LOCAL AGXNCY F�I Ty 1pN Iw/Ij APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E%PIRA710N DATE CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# FORM 8(6-29-88) THIS FORM MUST BE ACCOMPANIE YAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY