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I Al It OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM ='� Eft" TANK TANK PERMIT APPLICATION INFORMATION % COMPLETE ASEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. '.. ' MARK ONLY ❑ Q1 /�•EW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O/ 6 TEMPORARY TANK CLOSURE C)B TANK REMOVE K FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� L Y; y FARM TANK-YES❑ NO LI I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY PEAR TANK ID p B. MANUFACTURED BY: � ptl t,Ll C� AL 'W D. TANK CAPACITY IN GALLONS: ?ja 0- 11. TENTS IF(Al),IS YAKKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D µ TOR VEHICLE FUEL 2 PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL EMICAL PRODUCT F /OIL PRODUCT El A GASAHOL 5 JET FUEL 6 AVIATION GAS ZARDOUS ❑M EMPTY 95 UNKNOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN REM D,BELOW) TOR VEHICLE FUEL,ENTER NAME OFUS SUBSTANCE STORED&C.A.S.N CA.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,a D A TYPE OF ❑ 1 DOUNE WALLED El 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2i LLED A SECONDARYCONTAINMENT 99 OTHER B.TANK ❑ I N Z SINNLESSSTEEL E 7 fIBEFI RASS /STEEL CLAD WIFIBERGIASS REINFORCED PLASTIC MATERIAL ❑5 6 POLMNYLO LORDE ElI ALUMINUM D6 100%METHANOL COMPATIBLE FRP 9 10 GALVANIZED STEEL El 95 UNKNOWN E3 99 OTHER G INTERIOR 1 ED 2AUCTD LIMING [:]3 EPDXY LINING /PHENOUCUNING LINING ❑5 GLASS LINING ©6 UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH RK%METHANOL] YES []NO 0 99 OTHER D.CORROSION ❑ 1 POLYETHLENEWRAP 0 2 TAR OR ASPHALT 3 VINYL WRAP Ej 9 RBERGLASSHEINFORCFDPIASTC PROTECTION 05 CATHMC PROTECTION El 91 NONE 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 GflAVITY A U 91 NONE A U 95 UNKNOWN A U 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/LOON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U FIBERGLASS PIPE A U 9/ NONE C.wATERUL A U 5 ALUMINUM A U 6 CONCRETE A A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99SOTMERTEEL �W/FRP A U B 100%METHANOL COMPATIBLE FRP V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P B IVISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P B AELECTRONIC M P S 6 PRECISION TESTING P S T PRESSURE TESTING P S 91 NONE P S 9ONITOR P 8 SGROUNDWATER MONITOflING WELLS 5 UNKNOWN P S 99 VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE UST USED OT IMO/YH) 2. ESTIMATED QUANTITY OF 3. WA$TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIALi E_]GALLONS YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANTMME ME(POINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY p JURISDICTION• AGENCY Y �J FACILITY ID p TANK ID p CURRENT LOCAL AOENCY FACILITY ID 1 APPROVED By NAME PRONE•WTTN AIIEA CODE PERMIT NUMBER PERMIT AP ROVALO TE PERMIT EXPIRATION DATE CHECK PERMIT AMOUNT SURCHARGE T. FEE CODE CEIPTI BY: � 1'ORMB(5-29-m) THISFORYMUSTBEACCOMPANIED BY A FACILITT/SITE APPLICATION, FORM 'A' UNLESSACURRENT FORMA' HASBEENFILED DATA PROCESSING COPY _