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STATE OF CALIFORNI. WATER RESOURCES CONTRt ')ARD FORM 'S': UNDEA-GROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION TANK o COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .— o MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ERMANENTLY CLOSED TANK 10 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 4NW TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: Q 69 ��mo S � _FpRM T K-YES NO � 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK IDN B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /O 4'7 o II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ OTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL i PRODUCT ❑4 GASAHOL ❑ 5 FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL Fr99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CA.S.N PQQpce(IQ 6/ y" I C.A.S.N: -7A s-6 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A TYPE OF ❑ 1 BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM EVSINGUEWALUED ❑4 SECONDARY CONTAINMENT 99 OTHER F-11 STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS E]4 STEEL CLAD WYFIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7AOMINUM ❑B 1D0%METHANOLCOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL. W95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBERLINED ❑ 2 ALKYDUNING ❑3 EPDXYLINING 4 P LIC LINING LINING ❑5 GLASS LINING ❑6 UNUNED UNKNOWN ❑ IS LINING MATERIAL COMPATIBLEWTTH 100%METHANOL? YES ❑ NO WOTHER D PROTECTION ❑ 5 CATHODIC PROTECTION ❑91TNONE AR ASPHALT 3 V Z-VIKNOWN ❑99FOTLASS REINFORCED PIBERGLASTIC 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 95 UNKNOWN A U 99 OTHER R. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A CV95 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 SALUMINUM ;g CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL5 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. S 1 VISUAL CHECK P B 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? El YES E] NO � THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPUCANTS NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY ID a APPROVED BY NAME PHONE M WITH AREA CODE /frMOly PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE _ CHECKM PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTN BY:4. (N FORM B(6-29-ee) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM IN,UNLESS CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY