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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 N ERMIT ❑ 3 RENEWAL PERMIT -] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 10 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 10 FARM TANK-YES❑ NO z I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-$O SPECIFY I p A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED ! D. TANK CAPACITY IN GALLONS: (161 II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO LETS ITEM D. A, 1 MOTOR VEHICLE FUEL F-12 PETROLEUM C. UNLEADED E]2 LEADED E]3 DIESEL ❑ B.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&C.A.S.# All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,B D A. TYPE OF ❑ 1 DOU ALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM �.2'81/LE ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLAS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL TANK ❑5 CONCRETE E]6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVAMZEO5TEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR F-1i RUBBER LINED ❑2 ALKYDLI NG ❑ 3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING NED ❑95 UNKNOWN ❑IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2 TAR PHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A 05 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CUD W/FRP A U S 100%METHANOL COMPATIBLE FAP A U 9 GALVANIZED STEEL A 6)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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS 8 PRECISION TESTING P S 7 PRESSURE TESTING P B 91 NONE- P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED( O/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH /Ll / SUBSTANCE REMAINING IN INERT MATERIAL? ❑VES ❑ NO / GALLONS THIS FORM HAS B EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL AGENCY FA ILITY ID# APPROVED BY NANift PHONE WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RMIT XPIRATION TE CHECK# PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FORM B(3-7-BB) THIS FORM MUST BE ACCOMPANIED TY1 FACILITY/SITE APPLICATION, FORM 'A',UNLESS A COr.(ENT FORMA' HAS BEEN FILED V% 15A PROCESSING COPY