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STATE OF CALIFORP1'A WATER RESOURCES CON' IL BOARD FORM 'S': UNBERGROUND STORAGE TANK PAbGRAM TANK TANK PERMIT APPLICATION INFORMATION y % COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - z C MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PI FRYANENTLY CEO TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑9 TANK REMOVED (i FACILITY/BITE NAME WHERE TANK IS INSTALLED: l FARM TANK-YES O 1--1 I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (x A. OWNERS TANK ID p B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF 100),IS MARKED,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 ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ ' 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 6 CA.S.X C.A.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C.i D A TYPE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEEUIRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B,TANK ❑ 5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNNNOWN ❑99 OTHER ❑ C.INTERIOR I RUBBER LWFD ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASSLWWG ❑6 U4UNED ❑ 95 UNKNOWN ❑ IS LINING MATERALCOLIPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHENE WRAP ❑2TAR OR ASPHALT ❑ 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑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 I SINGLE WALLED A U 21 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP 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 { 1 VISUAL CHECK P B 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P E 4 ELECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P ! 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P E 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS I 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION# AGENCY p FACILITY ID 0 TANK ID f E2 = = v CURRENT LOCAL AGENCY FACILITY ID F /?/Hc- /6 APPROVED BY NAME O PH E E WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT E PIRATI DAYt CHECK F PERMIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT 1 BY: FORM B(6.29-60) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED F DATA PROCESSING COPY