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STATE OF CALIFOR1% WATER RESOURCES CONTRU-S80 RD�.n/1 - :,;rm FORM 'S': UNDERGROUND STORAGE TANK PROGRAM �_ TANK TANK PERMIT APPLICATION INFORMATION q �? o '^�o G COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' ' MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO NK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED Q FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3,470,) / ARM TANK VIES NO 1. TANK DESCRIPTION COMPLETE AII,LITEMS-IF UNKNOWN-SO SPECIFY �j�36 •C A. OWNERS TANK IDN Q'J 0. MANUFACTURED BY: C. YEAR INSTALLED c- D. TANK CAPACITY IN GALLONS: rte) �+] C 11. TANK CO NTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A1),IS NOT MARKED,COMPLETE ITEM D. C71 A. OTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL 3 CHEMICAL PRODUCT ❑ 4 OIL I PRODUCT ❑4 GASAHOL 05 JET FUEL E] 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN E]_2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STOHLD A C.A.S.N C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B.C,a D A TYPE OF LJ I DOUBLE WALLED ❑3 SINGLE WALLED WITH LXTUBOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL/IRON 2 STMNLESSSTEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ANERIAL ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM E]8 100%METHANOL COMPATIBLE FRP ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ I RUBBER LINED ❑2 ALKYD LINING ❑ 3 EPDXY UNING ❑4 PHENOLIC UNING LINING ❑ 5 GLASSLINING 6 UNUNED ❑ 95 UNKNOWN ❑ ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑ 99 OTHER D.CORROSION ❑ I POIYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS AE'INFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PHESSUHE A U 3 GHAVIIY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER 0.CONSTRUCTION A U I SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRRGLASSPIPE A U 9 ON A U 2 STAINLESS SI EEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 A 1 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FNP A U 8 IOU%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. P 8 1VISUALCHECK P S 21NVENTORYRECONCILIA110N P 8 3VADOSEWELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUNDWAIEHMONITORING WELLS P S 6 PRECISION TESTING P S 7 PHESSURETESTINO P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I. ESTIMATED DATE LAST USLD(MO/YH) 2. ESTIMATEDQUANTITYOF 3, WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL'! ❑YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APYLICAN I'9 NAML(PRINT hU A SIGNAI UHL) BAIL i LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY N FACILITY ID N TANK ID N CURRENT LOCAL AGENCY FACILITY 10 F APPROVED 8Y NAME PHONE N WITH AREA CODE W h-t.3 s' PERYITHUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK N PER AMOUNT SURCHARGE AMT. FEE CODE I uRM B(N-29-66) THIS fOHM MUST BE ACCOMPAN¢ BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY