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STATE,OF CALlF0R*k WATER RESOURCES CONIOL BOARD FORM 'S' UNDERGROUND STORAGE TANK PROGRAM e {[ y ,i TANK PERMIT APPLICATION INFORMATION TANK:" COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z 10 MARK ONLY �.-❑ 1 NEW PERMIT . ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑7 PERMANENT C SEO4A, ONE ITEM ,,. ❑ 2INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANKREMOVED�FACILITY/SITE NAME WHERE TANK IS IYES❑ C I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY A OWNERS TANK ID N B. MANUFACTURED BY: ve C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CO ENTS 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. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 1 OIL 1 PRODUCT ❑ K GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 CAS.N CAS.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A.B.C.LD A TYPE OF ❑ 1.DOUKEWAU.ED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLEWALLED ❑A SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 6 STEEL CLADWIF18EWAASS REINFORCED PLASTIC B.TANK ... ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORDE ❑ 7 ALUMINUM ❑ B IDNLORANOLCOMPATIBLEFRP MATERIAL,,:. :, . �❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C INTERIOR ❑ 1 RUBBERUNED ❑ 2 ALKYO UNING ❑ 3 EPDXYUNING ❑ 6 PHENOLICUNING LINING, ;` ❑ S GLASS UNING ❑ 6 UNUNED ❑95 UNKNOWN '❑ IS UNING MATERIAL COMPATIBLE WITH 100%METHANOL? [:]YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I POLYETHLENE WRAP ❑ 2 TAO OR ASPHALT ❑3 VIWLWRAP ❑6 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 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 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 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 95 UNKNOWN A U 99 OTHER A U I STEELIIRON A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE(PVC) A U I 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 8 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 1 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITOHMG WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 5 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MOIVR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [:] NO - GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED E SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N .I((�JJUURIISDICTI^ON N AGENCY N FACILITY ID f ` TANK ID N CUPRENT LOCALAGENCY FACILITY 10 P APPROVED BYNAME PHONE I WITH AREA CODE PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMITAMOUNT SURCHARGE AMT, FEE CODE ECEIPT I BY: j A . �, FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FO RM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED