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STATE OF CALIFORN' WATER RESOURCES CONTR_BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM .1Y TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INF ATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK 1 C3 ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 0- FACILITY/SITE NAPE WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO C71 N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY A A. OWNERS TANK ID N , B. MANUFACTURED BY: �llG Ql C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: - yj II. TANK C.011fiNTS IF(A1),18 MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. I MOTOR VEHICLE FUEL ❑2 PETROLEUMC. ❑ 1 UNLEADED LEADED IESEL ❑3 CHEMICALPRODUCT E] B.4 OIL a I 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 R CA.S.N C.A.S.p: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.A D A TYPE OF ❑ 1 TOEViiLLUED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM AL1LD ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER I STE AO4 ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC B.TANK ❑ MATERIALS CONCRETE ❑8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑8 IOIM METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ 99 OTHER ❑ C.INTERIOR I RRBERUNED ❑2 INING ❑3 EPDXYLINING E] 4 PHENOLIC LINING LINING ❑5 GUSS UMNO 8 UMINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IW%METHANOLI ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYETNLBVE WRAP ❑2 T ASPFMLT ❑3 WNYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHOOIC PROTECTKW 91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF AEIQVE OR D, U IF UNDERGROUND,SOT"IF APPLICABLE A SYSTEM TYPE I SUCTI A�U E A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A d 2 DOUG WALLED A U 3 LINED TRENCH A U 91 NONE A,C%UNKNOWN U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 6ALUMINUM A U 6CONCCRETE A U 7STEEL CUD W/FRP A U 8 IW9L METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A' 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 ( VISUAL CHECK P B 2 INVENTORY RECONCILIATION P B 3VADOSE WELLS P ECTRONIC MONITOR P B 5 GROUND WATER MONITORING WELLS P B 6 PRECISION TESTING P B 7 PRESSURE TESTING P S 91 NONE P- 95 UNKN N P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE UST USED(MO/YRI 2. ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH OALLON6 SUBSTANCE REMAINING IN INERT MATERIAL? Ej YES [:jNO 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 SIONATURE) DATE LOCAL AGENCY USE ONLY COUNTY E I JURISDICTION B AGENCY 1 FACILITY ID B TANK ID E CURRENT LOCAL AGENCY FACILITY 10 F APPROVED BY NAME PHONE F WITH AREA CODE PERMIT NUMBER PERNITAPPROVAL DATE PERMIT EXPIRATION DATE CHECK 1 PERYIT AMOUNT SURCHARGE ANT. FEE CODE RECEIPT F BY:: N' FORM a(a 29-Be) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED nATA PDnrceclur.. rnOV