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STATE OF CALIFOR',rA WATER RESOURCES CON„ X BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION �2; PERMANENTLY CLOSED TANK go ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE K flEMOVED �U FACILITY/SITE NAME WHERE TANK IS INSTALLED: ` FApM TANK-YES O N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY F- A. OWNERS TANK IDN B. MANUFACTURED BY: L( C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: G D O II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ I UNLEADED ❑ 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT 4 OIL1 PRODUCT 4 GASAHOL E]5 JET FUEL 6 AVIATION GAS 5 HAZARDOUS SO EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL 0 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A TYPE OF ❑ I DOUBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER UNKNOWN SYSTEM 2 SINGLEWALLED 4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEEUIRON 2 STAINLESS STEEL 3 FIBERGLASS Ej 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE 6 POLYVINYL CHLORIDE7 MINUM B 1DD%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE 10 GALVANIZED STEEL UNKNOWN 99 OTHER C. INTERIOR 1 RUBBERUNED 2 ALKYD LINING F-13 EPDXY LINING 4 PHEN LINING LINING ❑5 GLASS LINING 6 UNLINED UNKNOWN L] IS UNING MATERIAL COMPATIBLE WITH 10091 METHANOL? YES ❑ NO 99 OTHER D.CORROSION ❑ 1POLYETHLENE WRAP 2TAR OR ASPHALT 3W LWRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 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 'U 5 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 U 5 UNKNOWN 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 A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 1DO%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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. wtP 3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P—S6 PRECISION TESTING P S 7 PRESSURE TESTING S 91 NON P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE F GALLONS 1. ESTIMATED DATE UST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLFED WITH SUBSTANCE REMAINING IN 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(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY R FACILITY ID k TANK ID M CCS o 10 CURR LOCAL AGENCY FACILITY 10 N APPROVED j3Y NA p.� PHONE N WITH AREA CODE S oZ /; )/-- PERMITNUMBER PERMITAPPROVALDATE P RMIT EXPIRATION DATE CHECKN 7PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPTI BY: FORM B(6-29-BB) THIS FORM MUST BE ACCOMPANIED BY A FACILITYISITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY