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STATE OF CALIFORN' WATER RESOURCES CONTR�$OARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANKTANK PERMIT APPLICATION INFORMATION ANK. ° COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TZ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7�PERMANENTLY CLOSED TANK ONE ITEM ❑ 2 INTERIM PERMIT F-1 ❑.8 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE "TANK REMOVED N FACILITY/SITE NAME WHERE TANK IS INSTALLED: d� FARM TANK-YES Ll NO ❑ A I � I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ~ CO A. OWNERS TANK ID# B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) 5 HAZARDOUS 1:1 80 EMPTY El D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF CAS #: HAZARDOUS SUBSTANCE STORED&CAS.I7 III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,a D A TYPE OF ❑ 1 DOUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑ 8100%METHANOL COMPATIBLEFRP MATERIAL ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER F-11 RUBBER LINED ❑2 ALKYD LINING F-13 EPDXY LINING E] 4 PHENOLIC LINING C. INTERIOR LINING ❑ 5 GLASS LINING El6 UNLINED F-195 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 17 YES ❑ NO ❑ 99 OTHER 0. CORROSION ❑ 1 POLYETHLENEWRAP ❑ 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑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 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%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. P3 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 5 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P S I PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 5 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 SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? E]YES E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION# AGENCY R FACILITY ID# TANK ID N / 161 8 CURRENJ LOCAL AGENCY FACILITY IDN APPRO ED BY NAME PM NEN WITH AREA CODE Oa g PERMITHUMBER PERMITAPPROVALDA PERMI EXPIRA ON DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM B S-29-88) THIS FORM MUST BE ACCOMPANIE FAC K A ILITY/SRE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FILED DATA PROCESSING COPY