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STATE OF CALIFORI* WATER RESOURCES CONTROARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION q COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ;„ MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED )Z FACILITY/SITE NAME WHERE TANK IS INSTALLED: 5 ) FARM TANK-YES❑ NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A, OWNERS TANK ID# L_ B. MANUFACTURED BY: (. C. YEAR INSTALLED �/� D. TANK CAPACITY IN GALLONS. II. TANK CO ENTS IF(A.1),IS MApKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. W J A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OILPRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL E] 6 AVIATION GAS ❑ ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS E] Bp EMPTY [:] 95 UNKNOWN D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# �� C A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH Ex-ERIOR LINER ❑ 95 UNKNOWN SYSTEMSINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ I STEELPRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.MATERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEELKNOWN ❑99 OTHER C. INTERIOR I RUBBERLINED ❑ 2 ALKYD LINING ❑3 EPDXYLINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑6 UNLINED NOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE E�;,86-DRKNOWN ❑99 OTHER IV- PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A CU2 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. 1--�I1 P S 1 VISUAL CHECK �S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VVI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH N SUBSTANCE REMAINING IN GALLONS INERT MATERIAL' ❑YES [:jNO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# coo c �/ oc, o CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NA E PHONE#WITH AREA CODE 1qK9 le/C PERMIT NUMBER PERMIT APPROVAL DATE PE�RNIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY; FORM B(3-7-ee) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA HAS SEEN FILED DATA PROCESSING COPY