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STATE OF CALIFORNIA WATER RESOURCES CONTROL F�ARD , FORM 'S': UNDERGROUND STORAGE TANK PROG)rAM m� TANKTANK PERMIT APPLICATION INFORMATION TANK. ° b 3 COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH O MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C; K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6�T7EMPORARY TANK CLOSURE TANK REMOVED O FACILITY/SITE NAME WHERE TANK IS INSTALLED: ( 0 5 FARM TANK-YES❑ N CJI I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY Lq A A. OWNERS TANK ID N B. MANUFACTURED BY: C.YEAR INSTALLED (jj D. TANK CAPACITY IN GALLONS: rO 0 11. TANK CONTENTS IF( JS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D- A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUMB. C. E] 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL 1 PRODUCT ❑4 GASAHOL [--P FUEL E]6 AVIATION GAS ❑ 5 HAZARDOUS ❑80 EMPTY ❑ E]95 UNKNOWN ❑2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF V�� /_ / HAZARDOUS SUBSTANCE STORED 8,C.A.S.N V !T�N C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A TYPE OF ❑ BLE WALLED ❑3 SINGLE WALLED WITH EKTERN)R LINER ❑95 UNKNOWN SYSTEM NGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM F-16100%METHANOL COMPATIBLE FAP MATERIAL ❑9 BONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER 1 RUBBER LINED ❑2ALKYD UNING ❑3EPDXY LINING ENOUGUNING C. INTERIORN ❑5 GLASS UNING ❑6 UNLINED 95 UNKNOWN J ❑ISUNINGMATERALCOMPATIBLEWITH 109%METHANOL? YES NO 0 9 OTHER ldf- D. CORROSION ❑ 1 POLYETHIENEWRAP E]2 TAR OR ASPHALT ❑ INYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION [:]91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IFABOVEGROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A.SYSTEM TYPE A(Ull SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A 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 AuUNKNOWN 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 5 ALUMINUM ?U) 6 CONCRETE A U 7 STEEL CLAD WIMP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL 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. S 1 VISUAL CHECK P 5 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 S 7 PRESSURE TESTING P 8 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE L ES(MATED DATE LAST USED(MO/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? YES ❑NO 4ULLON8 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# IIrJURISDICTION#' III AGENCY# FACILITY ID# TANK IDS 1010101 /1 CURRENT LOCAL AGENCY FC ILITYI� �o APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE \ CHECK M"ITAMOUNT SURCHARGE AMT. FEE CODE I RECEIPT# FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESSURRENT FORMA HAS BEEN FILED DATA PROCESSING COPY