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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION �� TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATIONm_ 1 J FOR EACH TANK. _ _ Z' Ib MARK ONLY ❑ 1 NEWffRMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO A ONE ITEM INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED U FACILITY/SITE NAME WHERE TANK IS INSTALLED: S FApM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY Cil 3 A. OWNERS TANK ID R "3 B. MANUFACTURED BY W C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 P OLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT OIL ❑ 1 PRO ❑4 GASAHOL ❑ 5 JET EL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN WASTE ❑7 METHANOL OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.AC.A.S.P: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,8 D A TYPE OF ❑ I E WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM LLr SlNGp WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER SfEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 MEL CLAD W/FIBERGLASS REINFORCED PLASTIC S.TANK MATERIAL E-15 CONCRETE ❑6 POLYVINYLCHLORIDE [:1'7ALUMINUM ❑8100%METHANOL COMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑ 2 A15>tANG ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLA LINING NUNED %UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 1D0%METHANOL? ❑YES ❑ NO �990THEA ()A K D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TWORASPHALT ❑3 VINYLWRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ❑99 OTHER J IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, U IFUNDEUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLEWALLED A U 2 DOUBLE WALLED A 3 LINEOTRENCH A U 91 NONE A A 95 UNKNOWN A 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 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%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 8 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P 8 3 VAOOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P $ PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED O/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 4/A GALLONS SUBSTANCE REMAINING IN INERT MATERIAL? ❑VES ❑ NO J THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND-jORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY CrnrnNTY R JURISDICTION# AGENCY X FACILITY ID M TANK ID k CURRENT LOCAL AGENCY FACILIT'ID• APPROVED BY NAIPE PHONE N WITH AREA CODE 1a �� PERMIT NUMBER PERMIT APPROVAL DATE PEAMIT EXPIRATPA DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT BY: FORM B(6-29-es) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' NAS BEEN FILED DATA PROCESSING COPY