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STATE OF CALIFORNIA FORM `S': WATER RESOURCES CONTRO UNDERGROUND ARD GO TANK PROGMIAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK.MARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑3 RENEWAL PERA4R L-J5 CHANGE OF INFORMATION 2 INTERIM PERMIT AMENDED PERMIT ❑ 7 PERMANENTLY CLOSED TANK FACILITY/BITE NAME WHERE TANK IS INSTALLED: E]6 TEMPORARY TANK CLOSURE O ,,,,�-8 TANK REMOVED I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN_ lJ �rfIARM TANK-YES NO # A. OWNERS TANK ID# SO SPECIFY �IS1t, a. C. YEAR INSTALLED f B. MANUFACTURED BY: IV I1. TANK CONTENTS ) D. TANK CAPACITY IN GALLONS: IEEE] as IF(A.1,IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM 3 CHEMICAL PRODUCT 0 lFWAOS[T)E C. ❑ 1 UNLEADED LEADED4OIL 3 DIESEL 5 HAZARDOUS T 13 4 GASAHOL80 EMPTY 95 UNKNOWN ❑5 JET FUEL 6 AVIATION GAS D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ❑ 7 METHANOL HAZARDOUS SUBSTANCE STORED&C.A.S.# ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX q,B,C,$D C.A.S.#; A TYPE OF ❑1 DOUBLEWALIFD 11 3 SINGLE WALLED WITH EXTERIOR UNER SYSTEM 2 SINGLEWALLED 04 SECONDARYCONTAINMENT ❑95 UNKNOWN �'T-STEEUIRON [:3 2 ❑99 OTHER B. TANK STAINLESS STEEL �3 FIBERGLASS MATERIAL 0 5 CONCRETE ❑6 POLYVINYL CHLORIDE7 ALUMINUM 4 STEEL CLAD W/RBERGLASS REINFORCED PLASTIC 0 9 BRONZE ❑6 IN*METHANOL COMPATIBLE FRP E3 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER C.INTERIOR ❑ I RUBBERLINED El 2ALKYD LINING ❑3 EPDXY LINING 4 PHENOLIC LINING LINING ❑5 GLASS LINING 21—UNUNEO IS LINING MATERIAL COMPATBLENTH 100%METHANOL? ❑95 UNKNOWN 1:1 YES 0 NO E�)THER�Sd 14 D. CORROSION ❑1 POLYEiMLENE WRAP �2 TAA OR ASPHALT PROTECTION ❑3 VINYL WRAP 1:14 FIBERGLASS REINFORCED PLASTIC 5 CATHODICPROTECTKR! 91 NONE 2-99 UNKNOWN 99 OTHER IV. PIPING INFORMA ON CIRCLEA IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A.SYSTEM TYPE AJU.2 SUCTION A U 2 PpE;U B. CONSTRUCTION A U 1 SINGLE WALLED A A U 3 GRAVITY A U 81 NONE p U 2 DOUBLE WALLED A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER A U 1 STEEUIRON A U 2 STAINLESS STEEL A U 9/ NONE A1- 6 UNKNOWN A U 99 OTHER C. MATERIAL A U 5 ALUMINUM A D U 3 STEELpOLyYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE CONCRETE A U ?STEEL CLAD W/FRP A U 91 NONE A U 9 GALVANIZED STEEL A UNKNOWN A U B 100%METHANOL COMPATIBLE FRP 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 $ 2 INVENTORY RECONCILIATION P $ 3 VAppSE WELLS P $ q ELECTRONIC MONITOR P S S GROUND WATER MONITORING WELLS P S 6PRECISION TESTING P S ?PRESSURE TESTING P 8 91 NONE P S 96 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P $ 99 OTHER 1.ESTIMATED DATE LAST UBEDIMUIYK) 2 ESTIMATED OUANTI'Iy OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONB INERT MATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT. APPLICANTS NAME(PRINTED 6 SKiNATURE) DATE LOCAL AGENCY USE ONLY (C EEL JURISDICTION# AGENCY# FACILITY IDNTANK ID k FACILI TOR V 0'C APPH0 ED BY N E1611 PHONE R WRH AREA CODE PERYR APPROVAL DATEPERP EIIPIRATION DATE gM\t AMOUNT BUflCNARGE AMT. FEE CODE RECEIPTR BY;3YMUSTBEACC�IEA S(AFAC►ftTISITEAFPLICATION, FORM'A',UNLEs 3RENT FORMA' HASBEENFILED FOFNE ".--- " DATA PROCESSING COPY