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STATE OF CALIFORNIft WATER RESOURCES CONTR�ARD ^ ' FORM 'S': UNDE ROUND STORAGE TION INFORMATION ® TANK AM TANK PERMIT APPLICATION _> COMPLETE A SEPARATE FORM WITH THE FOLLOWING I ORMATION FOR EACH TANK. F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK MARK ONLY ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑e TANK REMOVED 70 Ik..� }� FARM TANK-YES❑ NO -r- FACILITY/SITE FACILITY/SITE NAME WHERE TANK IS INSTALLED: 7L- �,1 I ° ' I�AJ '::SJ I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY cn 4N. A. OWNERS TANK ID B. MANUFACTURED BY: G CYEAR INSTALLED D. TANK CAPACITY IN GALLONS: U . y O v II. TANK CqNTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. B C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑ 6 AVIATION GAS ❑ 5 HAZARDOUS ❑ 80 EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑ 99 OTHER(DESCRIBE/IN�ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.#: (V HAZARDOUS SUBSTANCE STORED&C.A.S.N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,&D 10 EWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 09 UNKNOWN A.TYPE OF ❑ 99 OTHER SYSTEM 2 SINGLE LLED ❑ 4 SECONDARY CONTAINMENT STEEL/IRON ❑ 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 ❑ 1 RUBBER LINED ❑ 2 APD ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C. INTERIORF-1 5 GLASS LINING UNLINED F-195 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 99 OTHER D.CORROSION ❑ I POLYETHLENEWRAP TAR OR ASPHALT ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFO��PLAST 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 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U ALUMINUM A U 6 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A/U/9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER O V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 5 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUNDWATER MONITORING WELLS P 8 6 PRECISION TESTING P S 7 PRESSURE TESTING �P S - NONE P 8 95 UNKNOWN P S 99 OTHER 1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE ESTIMATED QUANTITY OF 3. WAR TANK FILLED WITH 1. ESTIMATED DATE LAST USED(M /YR 2. SUBSTANCE REMAINING IN INERT MATERIAL? [:]YES [:] NO GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TANK ID# NTY k COUJURISDICTION# AGENCY# T7, APPROVED BY NA E ( PHONE#WITH AREA CODE CURRENT LOCAL AGENCY FACILITY IDM /D �/ Q o PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRAT NDATE CHECK# PERMIT AMOUNT SURCHARGE T. FEE CODE RECEIPT# BY: ft FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS AI RENT FORMA' HAS BEEN FILED S DATA PROCESSING COPY