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STATE OF CALIFORK ,,. WATER RESOURCES CONTR(—HOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE V8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: Ellis Car Wash FARM TANK-YES❑ NO ED 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDM B. MANUFACTURED BY Unknown O YEAR INSTALLED Unknow D. TANK CAPACITY IN GALLONS: 10000 Il. TANK CONTENTS IF(A1),IS MARKED,COMPLETE REM C.IF(At),IS NOT MARKED,COMPLETE ITEM D. A. ® 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 8C, ®1 UNLEADED ❑2 LEADED ❑3 DIESEL F-13 CHEMICAL PRODUCT ❑A OIL ® I PRODUCT ❑A GASAHOL ❑5 JET FUEL [j6 AVIATION GAS [j5 HAZARDOUS ❑80 EMPTY [:j95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.N C.A.S.M: Ill. TANK CONSTRUCTION MARK ONE REM ONLY IN SOX A.S.C,A D A TYPE OF ❑ I DOABLE WALLED ❑3 SNGLE WALLED WITH EIOERKNI LINER ❑95 UNKNDWN SYSTEM ®2 SINGLE WALLED ❑1 SECONDARY CONTAINMENT ❑N OTHER ® I STEEL/ROTI ❑2 STAINLESS STEEL ❑3 RBEWAASB ❑1 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 C04MTE ❑5 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑B 100%MERHAIOL OOIAPATIBU FRP MATERIAL ❑9 BNONZE ❑ 10 GALVANIZED STEEL ❑%UKNOWN ❑99 OTHER ❑ I RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑A PHENOLIC UNING C INTERIOR ❑5 GLASS LINING ®6 UNLINED ❑%mjmN LINING ❑G LINING MATERIAL COMPATIBLE WITH 100E AIETLAN(1LT ❑YES ❑NO ❑M OTHER r RROSION ❑ 1 POLYETIIENEWRAP ®2 TAI OR ASPHALT 3 VINYL WRAP ❑A RBERGLASSREINFOROMMASM TECTION ❑5 CATHODIC PROTECTION ❑91 NOIR ❑%UNKNWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,MOTH 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 E.CONSTRUCTION AM 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U %UNKNOWN A U 99 OTHER AOU 1 STEELIIRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL CUD W/FRP A U B IO METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U %OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST ME CIRCLED. F A I VISUAL CHECK P 9 2 INVENTORY RECONCILIATION P 9 3 VADOSE WELLS P M A ELECTRONIC MONITOR P M 5 GROUND WATER MONITORING WELLS 5 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P M 95 UNKNOWN P M 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE t ESTIMATED DATE UST USED(MO7YR) 2. ESTIMATED OOANTITY OFOAILOW 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:j NO THIS FORM HAS BEEN COMPLETED UNDER P NALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 6 SIGNATURE) DATE Lance Ellis J vMN►n / ('1 Q, 10-30-90 LOCAL AGENCY USE ONLY COUNTY S JURISDICTION P AGENCY I FACILITY ID F TANK ID S cuRPRNr LOCAL ADeNCv PACGTTY ID• APPROvco by NAME PHONE F WITH ARRA CODE �L� S PERMIT MUMMER PERMIT APPROVAL DATE PERMrt EKPNUTION DATE CHECK E PERYR AMOUNT MNICHARGE AMT. PEE CODE RECEIPT P MY: FORMBI9-292!) THIS FORM MMMEACOMAW WRAFACEJTYA mmo==K FORM'A',UMLESMACUMIBR NMM'A' IMMMEENFRED - 1 OATA..wOCESSING COPY 2 LOCAL AGENCY OOPM, MECOPY OPY