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STATE OF CALIFORN16 WATER RESOURCES CONTR&OARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM P= TANK TANK PERMIT APPLICATION INFORMATION o COMPLETE A SEPARATE FORM WITH THE FOLLOWING NFORMATION FOR EACH TANK. 10 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION MARK ONLY F-1 ❑ 7 PERMANENTLY CLOSED T❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED 1 FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 C • }' FARM TANK-YES 2fr NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W O A. OWNERS TANK ID# Q B. MANUFACTURED BY: IA--X- W C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: Dd D II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A7),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑2 LEADED 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑4 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 NAMEOF I HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: N A 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER STEEL/IRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 MEL CUD W/RBFRGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8100%METHANOLCOMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBERLINED 2 ALKYD LINING F--] 3 EPDXY LINING E]4 PHENOLIC UNING LINING ❑5 GLASS LINING 6 UNUNED ❑ 95 UNKNOWN�fy w/�' .�/ [:] IS LINING MATERIAL COMPATIBLE WITH 1011%METHANOL? ❑YES ❑ NO ©OTHER D. CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TARORASPHALT ❑ 3 V15L WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑ 91 NONE 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 A5 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 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM AP6 CONCRETE A U 7 STEELCLADW/FRP A U .8100%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. _)y, P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION S 3 VAD08E WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P S 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 1 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTI ATED DATE LAST USED(MO/YR) 2. ESTIMA ED QUANTITY OF 3.WAS NK FILLED WITH SU 5 NCE REMAINING IN J(1ATERIAL? ❑YES ❑ NO ^1 GALLONS 4 T IS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# CURRENT LOCAL A ENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE 7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXIIIRAYION DATE CHECKM PERMITAMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY