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STATE OF CALIFORK I WATER RESOURCES CONTI_. BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWIN .INFORMATION FOR EACH TANK. _ Z PERMIT 1 NEW MARK ONLY ❑ ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOS,..o. K 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: O xO �7 �(/ ,Q12ARM TANK-YES❑ NO ❑ 46 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY SZ(� 0) A. OWNERS -4 ANK ID# B. MANUFACTURED BY: CA C. YEAR INSTALLED I K3 D. TANK CAPACITY IN GALLONS' /L d Q II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NO 7 MARKED,C MPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. EVUNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT ❑4 GASAHOL ❑ 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.# C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D I BLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER F-] 95 UNKNOWN A TYPE OF ❑ SYSTEM LW SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑M OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 700%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR 1 RUBBER UNED [-]2 ALKYD UNIN4G ❑ 3 EPDXY LINING ❑ HENOUC LINING LINING ❑ 5 GLASS UNING ❑6 UNLINED 95 UNKNOWN Al lI ❑ IS LINING MATERIAL COMPATIBLE WITH IDD%METHANOL? ❑YES ❑ NO `Jo OTHER I Al D. CORROSION ❑ 1 POLYEIHLENEWRAP ❑2 TARORASPHALT ❑3 INYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 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 TJ i 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 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM AJL 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A/v`,7"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� / B 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWATER MONITORING WELLS dP 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P 8 99 OTHER V VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OFOALLONB 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES ❑ 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# 3 1 = = 1010 1 / 010101 :2- CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE S 7-e 6G 9� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECKN PERMIT AMOUNT I SURCHARGE AMT. FEE CODE RECEIPTM BY: p FORMB(6-29-88) THIS FORM MUST BE ACCOMPANI AFACILRY/SREAPPUCATION, FORM`A',UNLESS A ENT FORMA' HASBEENFILED DATA PROCESSING COPY