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STATE OF CALIFORNIll WATER RESOURCES CONTROWARD Pg " ' .; UNDERGROUND STORAGE TANK PROGRAM . m FORM 'S': TANK PERMIT APPLICATION INFORMATION o�y,, � z TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P MANENTLY CLOS MARK ONLY ❑ ❑q AMENDED PER ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED ® IV ONE ITEM ❑2 INTERIM PERMIT FARM TANK-YES❑ NO (J.7 FACILITY/SITE NAME WHERE TANK IS INSTALLED: N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SBE AN MANUFACTURED BY: A. OWNERS TANK ID# Z D. TANK CAPACITY IN GALLONS'. OD C.YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMEPALDETOE ITEM 2 LEADED �IESEL B. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM �y�PRODUCT ❑4 GA�HOL ❑5 JET FUEL 6 AVIATION GAS ❑ ❑4 OIL LJ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) E] 3 CHEMICAL PRODUCT 5 HAZARDOUS ❑ 80 EMPTY 95 UNKNOWN ❑2 WASTE F-1E] ❑ D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: HAZARDOUS SUBSTANCE STORED 8 C.A.S.# 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX ,B,C,&D ❑M UNKNOWN 1 UBNGLEWALLED LEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER A TYPE OF ❑�SI ❑q SECONDARYCONTAINMENT ❑ 93 OTHER SYSTEM 2 ❑2 STAINLESSSTEEL ❑ 3 FIBERGLASS ❑4 STEELCLAO WIFIBERGLASS REINFORCED PLASTIC B.TANK F-1 5 CONCRETE fi POLYVINYL CHLORIDE ❑T ALUMINUM 1 B 100%METHANOLWMPATIBLEFRP ONCRETE ❑ ❑ MATERIAL ❑9 BRONZE ❑ 10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 OUNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING C.INTERIOR 6 UNLINED ❑95 UNKNOWN LINING ❑5 GLASS LINING YE �-'��,A OTHER F-1ISUNING MATERIAL COMPATIBLEWITH 100%METHANOL? ❑ S ❑NO Liz" 1 POLYEFHLENEWRAp 2TAR OR ASPHALT �NYLWRAP ❑4FIBEPGLASS REINFORCED PLASTIC D. CORROSION ❑ ❑ ❑ PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPPLIC�ABN NE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A u SUCTION A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A 1 SINGLE WALLED A U 2 DOUOLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTH A 1 STEEL/IRON A U 2 CONCRETE STEEL A U 3 STEEL CLAD CHLORIDE(PVC) A U 4 FIRERGLAMETHANOL COA UIBLEF ONE C.MATERIAL A U 5 ALUMINUM 'ALy A U 9 GALVANIZED STEEL A 8�5 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 8 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS �0� P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING P 97 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 W TANK FILLED WITH 2.ESTIMAT QUANTITY OF 1 MATERIAL? ❑YES ❑ NO 1.ESTIMATEDDATE STUSED(MO/YR) SUBST 91REMAININGIN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN DATE LEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED B SIGNATURE) LOCAL AGENCY USE ONLY TANK ID N FACILITY ID N COUNTYN JURISDICTION � AGEO Go I Do APPNO_VED BY NA PHONE N WITH AREA CODE /'/V^ CURRENT LGGOCAL AGENCY FACILITY IDN `/�JA//� {^ NUMBER PERMIT APPROVAL DATE FERMI EXpIRAT10N DATE PERMIT CNECKN PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANILI. Y A FACILITYISITE APPLICATION, FORM 'A',UNLESS ENT FORMA' HAS BEEN FILED DATA PROCESSING COPY