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STATE OF CALIFOR�.A� WATER RESOURCES CONI <br /> '%a'L -'ARD � o '" <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM (a no <br /> TANK PERMIT APPLICATION INFORMATION „o, <br /> A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> TANK COMPLETE Zo <br /> MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM ❑ 2 INTERIM PERMIT F--j 4 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE E]8 TANK REMOVED f a 1 CN <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 1 ,50 FARM TANK-YES NO N <br /> (v <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# D B. MANUFACTURED <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL 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 95 UNKNOWN O 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS.#' <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.It <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,6 D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER F-1 95 UNKNOWN <br /> SYSTEM F�?<SINGLE WALLED F] 4 SECONDARY CONTAINMENT D 99 OTHER <br /> E�KSTEEJIRON F-1 2 STAINLESS STEEL [:] 3 FIBERGLASS 0 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK F--] 5 CONCRETE F-1 6 POLYVINYLCHLORIDE F-] 7 ALUMINUM F-� 8100%METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL F-] 95 UNKNOWN ❑ 99 OTHER <br /> 1 RUBBER LINED ❑2 ALKYD LINING 3 EPDXY LINING ❑4 PHENOLIC LINING <br /> 11 <br /> C. INTERIOR 5 GLASS UNING 8 UNLINED FT-] 95 UNKNOWN <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 0 VES E] NO F-1 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALTn 3f(WYL WRAP Ej 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [] 5 CATHODIC PROTECTION 1:191 NO 95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A a 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A®1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> 1)._L P S 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> �(J P S PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? YES [] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> m C� <br /> 1010 1 / 111 OOOI <br /> CURRENT LOCAL AGENCY FACI TY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> arf51 �1 <br /> PERMIT NUMBER PERMIT APPROVAL DA PERMIT EXPIRATION DATE <br /> CHECK N PERMIT AMOUNT 4URCHARGE ANT. FEE CODE N'"TEIPT# BY: <br /> FORM e(6-29-m) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />