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STATE OF CALIFORNIIS WATER RESOURCES CONTRO ARD <br /> FORM 'S': UNDE ROUND STORAGE TANK PRO AMI :; <br /> PLICATION INFORMATION <br /> TANK TANK PERMIT AP , <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. OMARK ON::R:�:EWERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDT NKONE ITEM PERMIT 4 AMENDED PERMIT Ej 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE w <br /> ,� / FARM TANK-YES NO W <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: W • 4�'�'�� ` ,A <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY cn <br /> A. OWNERS TANK ID# OZ' B. MANUFACTURED BY: <br /> C.YEAR INSTALLED 3 D. TANK CAPACITY IN GALLONS: 44 DOC) <br /> II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL r1 2 PETROLEUM B. C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL 1 PRODUCT ❑4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> 5 HAZARDOUS 80 EMPTY E 95 UNKNOWN 2 WASTE El 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> III. TANK CONSTRUCTION MARK ONE ITEM NLY IN BOX A,B,C,a D <br /> A.TYPE OF UBLEWALLED F-13 SINGLE WALLED WITH ESTERIOR LINER 95 UNKNOWN <br /> SYSTEM F�jl SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEBUIRON 2 STAINLESS STEEL F-1 3 FIBERGLASS E]4 STEEL CLAD WIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK F7 5 CONCRETE 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED n 2�'ob LINING 3 EPDXY LINING 4 PHENOLIC LINING <br /> C. INTERIOR 5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? �YES EINO 990THER <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP �2 TARORASPHALT 3 V LWRAP 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 APPLICABLE <br /> A SYSTEM TYPE A 1 SUCTION U PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> S. CONSTRUCTION A CUA SINGLE WALLED A 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 POLYVINYLCHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A g,6 CONCRETE A U 7 STEELCLADW/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZEDSTEEL A U A5 UNKNOWN A U 99 OTHER <br /> LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> S p VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS <br /> P S PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. E IMATED DATE LAST USED(MO/VR) 2. ESTIM ED QUANTITY OF 3.WAS TA KFILLEO WITH <br /> i"4 SUB NS'.E REMAINING IN GALLONS INERT A,�TERIAL? YES NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLE GE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> DU U <br /> CURRENT LOCAL AGENCY FACILITY ID# <br /> APPRO ED Y NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT AP ROYAL PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHA A FEE CODE RECEIPT# BY: <br /> FORMB(6-29-88) THIS FORM MUST BE ACCOMPANI B7J <br /> YAFACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORMAHAS BEEN FILED <br /> DATA PROCESSING COPY <br />