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WATER RESOURCES CONTRO ARD STATE OF CALIFORNIA UNDE OUND STORAGE TANK PROM :' FORM 'S': � TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. - ❑ 5 CHANGE OF INFORMATION ❑7 P MANENTLY CLO ANK 1 NEW PERMIT ❑3 RENEWAL PERMIT ANK REMOVED o 9 MARK ONLY ❑ ❑ 6 TEMPORARY TANK CLOSURE ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT jRM TANK-YES❑ NO n.+ FACILITY/SITE NAME WHERE TANK IS INSTALLED: / ra Ci I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY (p 8. MANUFACTURED BY: F WNERS TANK IDq D. TANK CAPACITY IN GALLOAR INSTALLED I� 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKC. ED,COMPLETE ITEM I UNLEADEDUNLEADED ❑ 2 LEADED ❑3 DIESEL B. A. ❑ 1 MOTOR VEHICLE FUEL EVPETROLEUM ❑4 GASAHOL ❑ 5 ET FUEL ❑6 AVIATION GAS PRODUCT ENT [-]3 CHEMICAL PRODUCT 4 OIL 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ ,/� Q ' D. IF NOT MOTOR VEHIICLE FUEL,STORED 8 C.A.S.IER NAME t J D 1 If /k/" C.A.S.N: HAZARDOUS �QI III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D A . ❑�OUBLE WALLED ❑3 SINGLE WALLEDWITHEXTERIOR LINER ❑95 UNKNOWN fLLLJJJ 4 SECONDARY CONTAINMENT ❑99 OTHER 2 SINGLE WALLED ❑ I STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD WIFISERGLASS REINFORCED PLASTIC F-1 5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP L ❑y BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER❑3 EPDXY LINING ❑4 PHENOLIC LINING ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING �T-T�,(R ❑ 6 UNLINED I?" KNOWN ❑5 GLASS UNING❑ IS LINING MATERIAL COMPATIBLE WITH I00%METHANOL? YES ❑ NO OTHER S10N ❑ 1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT r 3)UM1YLWRAP ❑ 4 FIBERGLABS REINFORCED FUSTIC TION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLIC9ABLE NONE A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE!Lf N A U 2 PRESSUREA U 3 GRAVITYB. CONSTIIUCTIWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 95 UNKNOWN A U 99 OTHERRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE IPVC7 R U 810%METHANOL COMPATIIB 9E FRONEC. MATERIAL A U 7 STEEL CLAD W/FRPUM A 6 CONCRETEIZED STEEL A U 95 UNKNOWN A U 99 OTHER V. AK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. AI/ p $ 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS fKJ P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P B 99 OTHER VI. NFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2.ESTIMATED QUANTITY OF INERT MATERIAL? YES ❑ NO 1. ESTIMATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNODATEEDGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID N COUNTY K JURISDICTION 8 AGENCY k FACILITY ID N mX018" � 006r[L-K-il AGENCY FACILITY I`NNDAPPROVED BY NAMEPNONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATEPERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORM-K HAS BEEN FILED DATA PROCESSING COPY