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STATE OF CALIFORNIA IDWATER RESOURCES CONTROLD FORM 'S': UNDERGROUND STORAGE TANK PROGR ;� = TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10Z MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT LSI~CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ©B TANK REMOVED W FACILITY(SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO CAJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 2 Il. TANK CONTENTS IF 00),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUMC. ❑ 1 UNLEADED E]2 LEADED ❑3 DIESEL CHEMICAL PRODUCT ❑ 4 OIL B. PRODUCT ❑4 GASAHOL ❑ 5 FUEL ❑ 6 AVIATION GAS VHAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF r, HAZARDOUS SUBSTANCE STORED&C.A.S.# J-"`��( �p LJY -I' C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF ❑�1 DOUBLE WALLED F-]3 SINGLE WALLEDWPTH EXTERIOR UNER ❑ 95 UNKNOWN ©2 SYSTEM SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ S 190%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED 5R2EL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBERUNED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC UNING C. INTERIOR 5 GLASS UNING 6al UNLINED ❑ 95 UNKNOWN LINING ❑ ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POLYEfHLENE WRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION Z91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, 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 Ag 95 UNKNOWN A U 99 OTHER i B.CONSTRUCTION A / 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 i STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W7FRP 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 S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSEWELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE ST US (MO/YR) 2. ESTIMATED QUANTITY OF3.WAS TANK FILLED WITH Z5/ R SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES Dq<o/ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID M TANK ID# EE = I I I 2 -- CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CMECKM PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPTN BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANI BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY