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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK PERMIT APPLICATION INFORMATION _ z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FARM TANK-YES❑ NO � FACILITY/SITE NAME WHERE TANK IS INSTALLED: F � 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY (� S. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: 50 C. YEAR INSTALLED .r7 11. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED 2 LEADED ❑3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 27EMPTY M Rz i PRODUCT ❑ 4 GASAHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ❑ ❑5 HAZARDOUS ❑ ❑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.0: HAZARDOUS SUBSTANCE STORED&C A.S.0 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOUBLEWALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN �! ❑4 SECONDARY CONTAINMENT ❑99 OTHER SYSTEM LYJ �SINGLEWALLED 1 STEELPRON ❑2 STAINLESS STEEL ❑ 3 RBERGLASS ❑ 4 MEL CIAO WIRBERGLASS REINFORCED PLASTIC B.TANK 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.INTERIOREl95 UNKNOWN LINING ❑5 GLASS LINING 6 UNLINED ❑ IS LINING MATERIALCOMPATIBLEWITH 100%METHANOL? ❑YES 0N 099 OTHER D. CORROSION ❑1 POLYETHLENEWRAP ❑2 TAR OR ASPHALT ❑ 3 VINYLWRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE rV95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 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 G. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEELIQED5 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 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 S PRECISION TESTING P S 7 PRESSURE TESTING P S 91 .ONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE S.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/VR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? YES NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODWLEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TAGENCY# FACILITY ID# TANK ID k COUNTY# JURISDICTION# [ail 1 �` CURRENT LOCAL AGENCY FACILITY ID p APPROVED BY NAME PHONE#WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ` PERMIT NUMBER A( 1 ECK# PERMITAMOUNT SURCHARGE AMT. FEE COD CHE RECEIPT k BYBy FORMB(6-29-Be) THIS FORM MUST BE ACCOMPANIED BYAFACIUTYPIO , O FORM A7,UNLESS, ,.0FORM 'A'FORA' HAS BEEN FILED DATAPROCESSING