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,:1Tr .4_. STATE OF CALIFORN WATER RESOURCES CONTF BOARD "'• FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. 10 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 0 7 PERMANENTLY��O 0-SFD TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT // ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVED 01 FACILITY/SITE NAME WHERE TANK IS INSTALLED: /7! -, 7 bs67 C�/�i�/1'f�"`"' �"`� K-YES❑ NO ❑ I.,. 53 --4 I. TANK DESCRIPTION COMPLETE ALL IT/EMS-IF UNKNOWN-SO SPECIFY � A. OWNERS TANK ID 8 - L� Q B. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: 11. ANKP6NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NT71:12ANOL LETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. ADED ❑2 LEADED DIESEL 3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCTHOL ❑5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.9: HAZARDOUS SUBSTANCE STORED&C.A.S.M III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D A TYPE OF ❑ I DOME WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM ❑ 2 SINGLEWALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEL71RON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/RBERGLAS4 REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 PDLYWNYL CHLORIDE ❑7 ALUMINUM ❑B 10696 METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY UNING ❑4 PHENOLIC UNING C.INTERIOR ❑ 5 GLASS LINING ❑6 UNUNED ❑95 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER D. CORROSION ❑1 POLYETHLENE WRAP ❑ 2 TAR OR ASPHALT ❑3 VIWLWRAP ❑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 A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 UNEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELPRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM A U 6CONCRETE A U 7STEEL CLAD W/FRP A U 8100%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 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS N P S 6 PRECISION TESTING P S 7 PRESSURETESTING P S 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 I SUBSTANCE REMAINING IN INERT GALLONS MATERIAL? ❑YES ❑NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE,IS TRUE AND CORRECT. iAPPLICANTS NAME(PRINTED B SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION# AGENCY N FACILITY IDR TANK ID# CURRENT LOCAL ACILITY IDN APPROVED BY NAME PHONE#WITH AREA CODE �G .26 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE /` -� CHECK# PER MIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# B�//�� FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SDATA PR TION, ORCOPY''UNLESS A CURRENT FORMA HAS BEEN FILED