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STATE OF CALIFORNIA WATER RESOURCES CONTROL 0; 4RD FORM 'S': UNDERGROUND STORAGE TANK PROG66A m� TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. MARK ONLY 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED ar FACILITY/SITE NAME WHERE TANK IS INSTALLED: ? FARM TANK-YES❑ NO CA) I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY AaCO A. OWNERS TANK IDR B. MANUFACTURED BY: V C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: �Q II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MID OR 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 ❑ 5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF /� � i .^ HAZARDOUS SUBSTANCE STORED 8 C.A.S.k I` C.A.S.q: Al N III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN SO%A,B,C,&D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER F795 UNKNOWN SYSTEM dSINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER 1 STEELARON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B.TANK rl MATERIAL F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8100%METHANGL COMPATIBLE FRP - ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER LINED ❑2 ALNYO LINING ❑ 3 EPDXY LINING ❑4 PHENOLIC LINING LINING ❑5 GLASS LINING 6 UNUNED ❑95 UNKNOWN A,� ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO OTHER tw�4J!!'./ D. CORROSION ❑ 1 POLYETHLENEWRAP ❑2TAR OR ASPHALT ❑3 VI LWRAP F-14 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE 1 SUCTIEON 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 SINGLWALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A UI 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 5ALUMINUM A6CONCRETE A U 7STEEL CLAD W/FRP A U 81 NM METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL AU 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 et 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS Po 6 PRECISIONTESTING P S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED D E LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF S WAS TANK FILLED WITH SUBSJV GALLONS AINING IN INE ATERIAL? E-]YES 0=N0 v{/ THIS F044 HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEbGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY , CONTY K JURISDICTION% AGENCY W FACILITY ID A TANK ID R m [Y I 10101A © I 0 1 CURRENT LOCAL AAGENCFACILITY IDM APPROVED BY INA PHONE PHONE N WITH AREA CODE PERMIT NUMBER PERMIT AP MALI IJ'`^/PERMIT EXPIRATION DATE J CHECK k PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT♦ BY: FORM B(6-29-88) THIS FORM MUST BE ACCOMPAkrO BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESVWCURRENT FORMA' NAS BEEN FILED DATA PROCESSING COPY