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%7 1 /4 c Ur s fALIrVrtNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK // TANK PERMIT APPLICATION INFORMATION V COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED. 5' M TANK-YES 21 NO ❑ LI 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY 7 ; d;r A. OWNERS TANK ID p B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IJ II. TANK 96NTENTS IF IRA).IS MARKED,COMPLETE ITEM C.IF IRA),IS NOT MARKED,P6MPLETE ITEM D. d A 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMB. C. lo'l UNLEADED ❑2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OILRODUCT ❑4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOM D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A CA.S.p CA.S.p: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,0,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑1 STEEUIRON E]2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD WIFIBERGUSS REINFORCED PLASTIC B. MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOLCOMPATIBLEFRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS UNING ❑6 UNLINED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ ND ❑ 99 OTHER D.CORROSION ❑ I POIYEFHLENE WRAP ❑2 TAR OR ASPHALT El 3 VINYL WRAP F-1 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFAS VE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A N2 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 A 95 UNKNOWN A U 99 OTHER A U 1 STEELAAON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 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. S 1 VISUAL CHECK P $ 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 3 4 ELECTRONIC MONITOR P 1 5 GROUND WATER MONITORING WELLS O 8 6 PRECISIONTESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 6 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING INOALLONB INERT MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. APPLICANT'S NAME(POINTED&SIGNATURE) DATE 4 LOCAL AGENCY USE ONLY COUNTY p JURISDICTION 0 AGENCY p FACILITY ID# TANK ID p ® = = I dd l o e o CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE 1 WITH AREA CODE 462 M 9Z I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CNEGNE PERMITAMOUNT SURCHARGEAMT. FEE CODE RECEIPT• FORM B(&n.m) THIS FORM MUST BE ACCOMPAMWBY A FACIUTY/WTE APPLICATION, FORM 'A',UNLESS URRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY