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r STATE OF CALIFORNII WATER RESOURCESCONTR BOARD FORM 'S'' UNDERGROUND STORAGE TANK PROGRAM _vim o TANK. TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. F-13 RENEWAL PERMIT CHANGE OFINFORMATION ❑7 PERMANENTLY CLOS MARK ONLY ❑ 1 NEW PERMIT W ONE ITEM ❑2 INTERIM PERMIT ❑/AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑6 TANK REMOVED / r�A MTANK-YES NO ❑ FACILITY/SITE NAME WHERE TA14KIIS INSTALLED: i I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY 6 B. MANUFACTURED BY: A. OWNERS TANK IDK C.YEARINSTALLED U D TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED ❑ 2 LEADED ❑ 3 DIESEL A. ❑1 MOTOR VEHICLE FUEL ❑2 PETROLEUM ❑3 CHEMICAL PRODUCT ❑4 OIL ❑ 1 PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑BB EMPTY 95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF - C.A.S.K: ` HAZARDOUS SUBSTANCE STORED&C-AA K III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,ED A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM F-12 SINGLE WALLED ❑4 SECONDARY CONTAINMENT E]99 OTHER , ❑I STEEURON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑/STEEL CIAOWIFIBEflGUSS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE 7 AL00111M 0.8 Ion METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑19 GALVANIZED STEEL. UNKNOWN ❑99 OTHER ❑1 RUBBERUNFD ❑2 ALKYDUNING ❑3 EPDXY LINING ❑/ UCUMNG C.INTERIOR ❑5 GLASS LINING ❑6 UNLINED 10 UNKNOWN LINING F-1IS LINING MATERIAL COMPATIBLE WITH IDA METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑ 1 POLYETHLEFIE WRAP ❑2 TAR OR ASPHALT 3 WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 7 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A C95 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(Uj 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 ALUMINUMCONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A A U 9 GALVANIZED STEEL U 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 6 3 VADOSE WELLS P ELECTRONIC MOK(ITQ P 8 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURETESTING P 8 91 NONE 8 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE !''• ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH 2. 1. ESTIMATED DATE LAST USED(MO/VR) SUBSTANCE REMAINING IN INERT MATERIAL? YES E] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID k TANK ID N JZ�E © Coy CURRENT LOCAL AGE14CY FACILDIk „��/�� APPROVED BY NAME PHONE N WITH AREA.WDE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHI PERMIT AMOUNT SURCHARGEAMT. FEECODE I.,RECEIPT N BY: (/✓ FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',U IIRENT FORM W NAB BEEN FILED �J sT'ATA PROCESSING COPY