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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. Z z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED O , W FACILITY/SITE NAME WHERE TANK IS INSTALLED: amuf _i t-1 FARM TANK-YES❑ NO w CD I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY fD A. OWNERS TANK ID 4 8. MANUFACTURED BY: w C YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK 9ONTENTS IF(A I),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE REM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. [::] I UNLEADED ❑ 2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL Q/1 PRODUCT [:j4 GASAHOL ❑5 JET FUEL E]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 8 C.A.S.R C.A.S.N: III. TANK CONSTRUCTION MARK ONE REM ONLY IN BOX A 8,C,AD A. TYPE OF ❑1 DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTEROR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑4 SECONDARYOONTAINMENT ❑99 OTHER ❑ 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 OD4QREfE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 10D%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANZED STEEL ❑95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING ❑6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYMCENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWMP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODICPN)TEC710N ❑91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGROUND, 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 1 SINGLE WALLED A U 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 RBERGLASSPIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A U 6 CONCRETE A U 7 STEELCIAD 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. 04 P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING ■ 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2.ESTIMATED OLIANTITY 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. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S - JURISDICTION R AGENCY P FACILITY ID B TANK ID M ® I I / 5 3 CURRENT LOCAL AGENCY FACILITY ID 4 APPROVED BY NAME PHONE 8 WITH AREA CODE N FL-5 PERMIT NUMBER PERMIT APMOVAL DATE PERMIT EXPIRATION DATE CHECK 6 PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT P BY: FORM B(6-29.881 THIS FORM MUST BE ACCOMPANIED e,-A FACILITY/SITE APPLICATION. FORM 'A'.UNLESS A CURRFNT FOR74'A' 4A!RePN FILFD