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STATE OF CALIFORNIA WATER RESOURCES CONTRq&OARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROJW <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. •��"' p' <br /> MARK ONLY ❑ 1 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION �7 P ANENTLY CLOSED T I d <br /> ONE ITEM Ej 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED O <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES NO N <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> to <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: c <br /> C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: OO <br /> II. TANK CONTENTS IF(A.1),IS MA KED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. F-] 1 MOTOR VEHICLE FUEL 2 PETROLEU B. C. 1 UNLEADED 2 LEADED E] 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL r-11 PRODUCT 4 GASAHOL 5 JET FUEL ❑6 AVIATION GAS <br /> E 5 HAZARDOUS 80 EMPTY [0:]%95 NOWN 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN B A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTER LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED 4 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3 FIB GLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> it B.TANK F-]5 CONCRETE 6 POLYVINYLCHLORIDE 7 ALUM[ <br /> MATERIAL 8 100%METHANOL COMPATIBLE FRP <br /> it0 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOW 99 OTHER <br /> C. INTERIOR <br /> F-] 1 RUBBER LINED 2 ALKYD LINING E] 3 EPDXY LINING D 4 PHENOLIC LINING <br /> LINING ❑5 GLASS LINING 6 UNLINED 95 UNKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES [:]NO 99 OTHER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP 2 TAR OR ASPHALT 3 VINYL WRAP 4 FRGLASS REINFORCED PLASTIC <br /> PROTECTION [:]5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN F 99 0TH <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPL ABLE <br /> A.SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U NONE A U 95 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 hQNE A U 95 UNKNOWN A U 99 OTHER <br /> 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 <br /> C. MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A 8 100%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 DETECIITN SYSTEM MUST BE CIRCLED. <br /> P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 OUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 O HER <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 I <br /> INERT MATERIAL? DYES [::] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> m131 / � <br /> CURRENT LOCAL Ag"WY FACILITY ID# APPROVED Y NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBE PERMIT APPROVAL DATE P MIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT URCHARGE AMT. FEE CODE R EIPT# BY: <br /> r <br /> FORM B MFORM MUST BE ACCOMPANIED A FACILITIUSITE APPLICATION, FORM `A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> (J DATA PROCESSING COPY. <br />