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t .; ;. I -V;. t STATE OF-CALIFORNIA WATER RESOURCES CONTROL`�' ; ARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM uo TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE;FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z IO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANKCL05URE ❑8 TANK REMOVE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 0 g;;A 6 RM TANK-YESun NO ❑ N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY A. OWNERS TANK ID# B. MANUFACTURED BY: OD' C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: IL TANK CONTENTS IF(A•1).IS MARKED,COMPLETE ITEM C.IF(A.1),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 ❑ BO EM 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) 0. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# w C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 1:9<5 UNKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑ 4 SECONDARY CONTAhNMENT ❑ 99 OTHER ❑ 1 STEEL/IRON ❑ 2 STAINLESS STEEL ❑3 FIBERGLA ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 AL UM ❑ B 100%METHANOL COMPATIBLE FRP MATERIAL ❑ 9 BRONZE E] 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER C. INTERIOR F—] 1 RUBBER LINED El2 ALKYD LINING ❑ 3 EPDXY LINING 4 P OLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED UNKNOWN t ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT 3 PINY WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Eaa5UNKNOWN ❑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 A 95 NKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SfNGLE 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 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM ACONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 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. P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 5 3 VADOSE WELLS P ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 5 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 91 NONE S 5 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF rY 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN , INERT MATERIAL? ❑YES ❑ NO GALLONS THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) F` I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# LIJ . 1. 1= 411 / 1-7I D CURRENT LOCAL ACEI Y FAC TY 1D k APPROVED BY NAME PHONE N WITH AREA CODE cUL�r/j( PERMIT NUMBER PERMIT IV APPROVAL DATE PERM ITEXPIRATION DATE PERMIT NUMBER 7� CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM'A' HAS BEEN FILED DATA PROCESSING COPY,,,