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STATE OF CALIFORN* WATER RESOURCES CONTR OARD FORM 'S': UND GROUND STORAGE TANK PR4RAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWIN INFORMATION FOR EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 flENEWAL PERMIT 5 CHANGE OF INFORMATION ° ONE ITEM ❑2 INTERIM PERMIT ❑ 7 MANENT CL T NK ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 6 TANK gEMO ED FACILITY/SITE NAME WHERE TANK IS INSTALLE 4-0M17Q ARM TANK-YES I. TANK DESCRIPTION COMPLETE ALL ITEMS-IFU KNOWN-SO SPECIFY A. OWNERS TANK ID M B. MANUFACTURED BY: C. YEAR INSTALLED .w, D. TANK CAPACITY IN GALLONS: II. TANK C LATENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. µ 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 EMPTY ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 8 C.A.S.M C.A.S.M: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BO%A,B,C,8 D [B. TANK PE OF ❑ I DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNE ❑95 UNKNOWN STEM 2 SINGLEWALLEO 4 SECONDARYCONTAINMENi 99 OTHER I STEEL/If10N 2 STAINLESSSTEEL ❑3 FIBERGUSS4 STEEL CIAD W/FIBERGLASS REINFORCED PLASTIC TERIAL 5CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER I RUBBER LINED 2ALKYD UNING. TERIOR ❑ ❑3 EPDXY LINING ❑4 PHENOUCUNING LINING ❑ 5 GLASS UNING ❑6 UNUNED 95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IOD%METHANOL? ❑YES ❑NO ❑990THER :: D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TARORASPHALT ❑3 VIWL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE ❑95 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 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 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 A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL CLAD W/FRP A U B 10096 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 S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P g 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S S GROUND WATER MONITO�WELLS P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P g 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY Of 3. WAS TANK FILLED WITH SUBSTANCE REMAINING IN INERT MATERIALS GALLONS ❑YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION N AGENCY* FACILTY IDM TANK ID M 9 [U� I3 CURRENT LOCAL AGENCY FACILITY ID M ,I 0 APPpOVED BYNAME PHONE 0 WITH AREA CODE �`\ PERMIT NUMBER /� PERMIT APPROVAL DATE PERMIT EXPIRATION GATE CHECK# PERMIT AMOUNT 3 SURCHARGE AMT. FEE CODE RECEIPT( BY: FORM B(6.29-86) THIS FORM MUST BE ACCOMPA I) ACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY