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STATE OF CALIFORN, WATER RESOURCES CONTR .BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM :n , TANK `-''COTANK PERMIT APPLICATION INFORMATION `� ' MPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOS ONE ITEM ❑2INTERIM PERMIT ❑ A AMENDEDPERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVE ('J FACILITY/SITE NAME WHERE TANK 13 INSTALLED: S (/ L ARM TANK-YES NO ❑ IV I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY �7 A. OWNERS TANK ID B LLo B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 32V te: 1 II. TANK C TENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. /1 A. KI MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. E] 1 UNLEADED 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑{OIL 1 PRODUCT] 1 GASOHOL ❑ 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 8 C.A.S.N C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,i D A TYPE OF ❑ 1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 SINGLE WALLS ❑ 1 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGUM A STEEL CIADW/FIBERGLASS REINFORCED PLASTIC B.TATERUL. ❑ 5 CON( m ED POLYVINYLCHLORIDE ❑ 1 ALUMINUM ❑B IM METHANOL COMPATIBLE FRP 9 BRONZE ❑ IB GALVANIZEDSTEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RU MUNED ❑2 MOD LINING ❑3 EPDXY LINING ❑A PHENOLIC LINING LINING ❑5 GUSSLNING ❑6 UNLINED ❑95 UNKNOWN ❑ ISUNINGIAATUMCOMPATIBLEMTH160%METHANOL7 ❑YES ❑ NO ❑99 OTHER D.CORROSION ❑ 1 POLYETHLFNE WRAP ❑2 TARORASPHALT ❑ 9 VINYL WRAP ❑A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PR OTECRON ❑ 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 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 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLADWIFRP 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 6 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P 8 A ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING 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 UATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:]NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION P AGENCY P FACILITY ID B TANK 10 8 CURRENT LOCAL AGENCY FATY IDI APPROVED BY NAME PHONE I WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /tr- CHECK I PERMIT AMOUNT SURCHMIOE AMT. FEE CODE ECEIPT F BY: / FORM a(6-2frIM) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED