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STATE OF CALIFORN* WATER RESOURCES CONTR OARD FORM 'S': UND GROUND CrORAGE TANK PR DRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE ASEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. m MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT❑ f•` �> ;eONE ITEM ❑ E OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 10 2 INTERIM PERMIT ❑q AMENDED PERMIT ❑ 5 CHANGE TEMPORARY TANK CLOSURE FACILITY/SITE NAME WHERE TANK IS INSTALLED: ❑8 TANK REMOVED N o FARM TANK-YES❑ NO LrI I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SO SPECIFY A. OWNERS TANK ID# � a) B. MANUFACTURED BY: rN \) C. YEAR INSTALLED U D. TANK CAPACITY IN GALLONS: SaD 11. TANK CONTENTS IF(A.1),IS MApKED,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 E]3 CHEMICAL PRODUCT ❑4 OIL ❑5 HAZARDOUS ❑ ❑3 DIESEL rl PRODUCT E]4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS D. IF NOT MOTOR VEHIC ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE 7 METHANOL E]99 OTHER(DESCRIBE IN ITEM D,BELOW) LE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D C.A.S.#: A TYPE OF ❑ I DWBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM ❑2 SINGLE WALLED 95 UNKNOWN E ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON2 STAINLESS STEEL B.TANK � ❑ ❑3 FIBERGLASS ❑4 STEEL CLAD W/FlBERGLASS REINFORCED PLASTIC MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7UNKINUM ❑8 100%METHANOL COMPATIBLE RIP ❑9 BRONZE ❑10 GALVANIZED STEEL NOWN ❑99 OTHER ❑ 2ALKYO LINING C.INTERIOR 1 RUBBERUNED ❑ ❑3 EPDXY LINING n q BINKNOW LINING LINING ❑5 GLASS UNING ❑6 UNLINED (J��,/ ❑IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? 95 UNKNOWN ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENEWRAP ❑2 TARORASPHALT 3 WRAP PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑<FIBERGLASS REINFORCED PLASTIC 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM A U 1 SUCTION A U 2 PRESSURE B.CONSTRUCTION A U 1 SINGLE WALLED A U 3 GRAVITY A U 91 NONE UNKNOWN A U 99 OTHER A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 1 STEELPRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A AU U919NONE ER C. MATERIAL A U s ALUMINUM CONCRETE A U 7STEELCLADW/FRP A U 9 GALVANIZED STEE A U #KNOWN 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING -ELECTRONIC MONITOR P 8 91 NONE P S 5 GROUNDWATER MONITORING WELLS P UNKNOWN P S 99OTHER - 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? ❑YES ONO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, 8 SIGNATURE) IS TRUE AND CORRECT. APPLICAM'S NAME(PRINTED DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# I TANK ID# C ENT LOCAL AGENCY FACILITY IDN N Ary APPROVED BY NAME PHONE N WITH AREA CODE PE UMBER 7 APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMITAMOUNT IL URCMARGEAMT. FEE CODE EIPTM BY: FORM s(6-2s-efi) TNIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS SEENFILED 6 DATA PROCESSING COPY