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STATE OF CALIFORNhi WATER RESOURCES CONTRPBOARD <br /> FORM 'S': UND GROUND STORAGE TANK PR GRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION (02 <br /> ��- COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL ,C <br /> ONE ITEM E12 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMP TANK CLOSURE B TANK REMOVED / <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: ,;l L" , S ' 1�ti p TANK-- NO N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY cz) <br /> CO <br /> A. OWNERS TANK IDK B. MANUFACTURED 8 : CO <br /> C. YEAR INSTALLED U(L' D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT ❑ 4 OIL —Fll 0 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> E] 5 HAZARDOUS LO EMPTY �95UNKNOWN 2 WASTE 0 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.K CAS,N. <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,8,C.a 0 <br /> A TYPE OF ❑ 1 DOUBLE WALLED Ej 3 SINGLE WALLED WITH EnERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEELARON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CUD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM <br /> MATERIAL B 100%METHANOL COMPATIBLE FAP <br /> E] 9 BRONZE E] 10 GALVANIZEDSTEEL 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBERLINED 2ALKYDUNING 3EPORYLINING 4PHENOLICUNING <br /> LINING ❑ 5 GLASS LINING 6 UNUNED ❑95 UNKNOWN <br /> ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? 0 YES I--] NO El 99 OTHER <br /> D.CORROSION ❑ I POLYETH(ENE WRAP ❑2 TARORASPHALT 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION [:]91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICA13LE <br /> 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 <br /> 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 <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U 95 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 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE UST USED(MO YYR7 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? DYES E] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 6 SIONATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY/# JURISDICTION# AGENCY# / 61FA(CIILLITY ID K T(ANKIDK <br /> CURRENT LOCAL AGENC FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER <br /> PER APPROVAL DATE PERMIT EXPIRATION DATE <br /> 7-�f-kq <br /> CHECK I PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT I BY; <br /> FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />