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STATE OF CALIFORNIA WATER RESOURCES CONTROL )ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. O I JAI - t l.1 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: l.' RM TANK-YES❑ NO EO- x-- I. TANK DESCRIPTION COPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY -V� A. OWNERS TANK IDA B. MANUFACTURED BY: 00 C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: /My 11. TANK C NTENTS IF(A.1),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 ILLI 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 REM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.K CAS.K. 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑2 GLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEELIIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYWNYL CHLORIDE ❑ 7 ALUMINUM ❑8 1 OD%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER -- F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING ❑d NOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING F-16 UNLINED 95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES NO ❑99 OTHER D. CORROSION ❑ 1 POLLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 LWRAP ❑ /FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFA !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 8. CONSTRUCTION A U 1 SINGLE WALLED A 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 5ALUMINUM A CONCRETE A U ISTEELCLADW/FRP A Al 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. D/ S I VISUAL CHECK P 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS (> P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE it 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES ❑NO � THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. 1 APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 8 JURISDICTION A AGENCY Y FACILITY ID q TANK ID k CURRENT LOCAL AGENCY FACILITY ID A #0ATE Y NAME PHONE F WITH AREA CODE PERMIT NUMBER PERMIT APPROVALPERMIT EXPIflAT10N OA�PERMIT AMOUNT SURCHARGEANODE ^ECEIPT 4 BY: rnnla P le a3.ggl THIS FORM MUST BE ACCOMPANIE.,eY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A,dRRENT FORMA' HAS BEEN RILED DATA PROCESSING COPY