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STATE OF CALIFORNIWATER RESOURCES CONTROL ARD <br /> FORM 'S': UNDER OUND STORAGE TANK PRO M ; <br /> TANK TANK PERMIT APPLICATION INFORMATION - ° <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> I:J <br /> '�a,lr rri..n r;rP. wr� <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION I <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 7 ANK REMOVED CLO <br /> SED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED. ❑ <br /> FARM TANK-YES NO <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK la# <br /> B. MANUFACTURED BY: <br /> C. YEAR INSTALLED / <br /> D. TANK CAPACITY IN GALLONS: O <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1 ,7S NOT MARKED,COMPLETE ITEM D. <br /> 7[F:-13 <br /> EHICLE FUEL �2 PETROLEUM B. C. � 1 UNLEADED �2 LEADED <br /> 3 DIESEL <br /> L PRODUCT q OIL1 PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GASUS ep EMPTY D 95 UNKNOWN D 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW)VEHICLE FUEL,ENTER NAME OFBSTANCE STORED&C.A.S.# <br /> C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A. TYPE OF i DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER g5 KNOWN <br /> SYSTEM 2 S LE WALLED d SECONOARYCOMTAINMENT <br /> 9 OTHER <br /> B. TANK 1 STEELIIRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAD WJFIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 6 10096 METHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED D 2 ALKYD LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING 5 GLASS LINING 6 UNLINED UNKNOWN <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES IJ NO [� N OTHER Ul <br /> D.CORROSION I POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION a 5 CATHODIC PROTECTION 91 NONE <br /> 95 UNKNOWN 99 OTHER <br /> 1V. PIPING lNFORMA ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A SUCTION A U 2 PRESSURE "A' U 3 GRAVITY <br /> 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 U99 OTRER <br /> A U 1 STEELIRON A U 2 STAINLESS STEEL A V 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE <br /> A U 7 STEEL CLAD WlFRP A U 8 1 pp%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 5 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P 5 2 INVENTORY RECONCIDATiON P S 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR p <br /> hM P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S S GROUND WATER MONITORING WELLS <br /> P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> V!. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3.WA 5 TANK FILLED WITH <br /> INERT MATERIAL? �YL <br /> N0 <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT, R <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> DATE V <br /> ::: <br /> LOCAL AGENCY USE ONLY <br /> 7COUNT71Y# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> � C <br /> RRENT LOCAL AG CY FACILITY ID A <br /> / '� APPROVED BY NAME <br /> ��! PHONE X WITH AREA CODE <br /> T NUMBER <br /> PERMIT APPROVAL DATE P MIT EXP ATION DATE <br /> PERMIT AMOUNT SURCHARGE AMT. FEE CODE <br /> RECEIPT M BY: <br /> ae) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A riENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />