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STATE OF CALIFORN' WATER RESOURCES CONTR_ BOARD "•� *' FORM 'S': UNDERGROUND STORAGE TANK PROGRAM : L'_ TANK PERMIT APPLICATION INFORMATION .', TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWIN FORMATION FOR EACH TANK. Z 10 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED T ONE ITEM 02 INTERIM PERMIT ❑1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED 0 w FACILITY/SITE NAME WHERE TANK IS INSTALLED: M TANK-YES❑ NO IV 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK IDN f I B. MANUFACTURED BY: C. YEAR INSTALLED O. TANK CAPACITY IN GALLONS: 11. TANK C941ENTS IF(A•1).IS MARKED,COMPLETE ITEM C.IF(A.1),I OT MARKED,COMPLETE ITEM D. A 3 MOTOCHEMR VEHICLEAL FUELUCT ❑ A PETROLEUM B 1 Pfl000CT C ❑ I UNLEADED ❑ 2 LEADED 3 DIESEL A GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑5 HAZARDOUS ❑LD EMPTY ❑95 UNKNOWN ❑2 WASTE ❑ T METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED A C.A.S.9 C A.S.I: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C.E D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 1 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVIWLCHLORIDE ❑ Z ALUMINUM ❑6 IW%METHANOL COMPATIBLE FRP MATERIAL.. . ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C INTERIOR ❑ 1 RIMER LRED ❑2 MOD LINING f73 EPDXY UMNG ❑ /PHENOLIC LINING LINING ❑ 5 GLASS EWING ❑6 LkJNEO 95 UNKNOWN ❑ IS UNWG MATERIAL COMPATIBLE WITH IBD%METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POIYETHLENE WRAP ❑2 TAR OR ASPHALT ❑7 WNYL WRAP ❑ I fI6ERGlA55 REINFONCED FUSTIC PROTECTION ❑ 5 CATHODIC PNOTECIKIN ❑91 NOW ❑95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U-95.UNKNOWN Au 99 OTHER B.CONSTRUCTION A U I 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 I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U A 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 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. P 6 1 VISUAL CHECK P t 2 INVENTORY RECONCILIATION F 6 3 VADOSE WELLS P G I ELECTRONIC MONITOR P 5 5 GROUND WATER MONITORING WELLS F 6 6 PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE 0 6 95 UNKNOWN P 6 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANTITY OF 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN OALLONt INERT MATERIAL? F]YES E:] NO THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY E JURISDICTION E AGENCY E FACILITY ID Y TANK ID I I I I EE= 0o I G / CURRENT LOCK AGENCY FACILITY 1)1 APPROVED BY NAME PHONE I WITH AREA CODE M A I S/ PERMIT NUMBER PERMIT APPROVK DATE PERMIT EXPIRATION DATE CHICK PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: J�l�./ HOIIMB(e-29-M) THIS FORM MUST BE ACCOMPANIED BYAFACIUTY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED �/