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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION (oz COMPLETE A SEPARATE FORM WITH THE FOLLOWINGI ORMATION FOR EACH TANK.MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 10 ONE ITEM ❑2 INTERIM PERMIT ❑7 PERMANENTLY CLOS TANK ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SPECIFY FARM TANK-YES NO ED A. OWNERS TANK ID B. MANUFACTURED BY: A C. YEAR INSTAEN D LL 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 LPROICLDUCT ❑ 2 PETROLEUM B. C. O 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 L]95 UNKNOWN ❑2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED 6 C.A.S.4 n C.A.S.M 'v III. TANK CONSTRUCTION MARK ONE ITEM ONL IN BOX A,B,C,B O A TYPE OF ❑ UBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNER ❑95 UNKNOWN SYSTEM 012 SINGLE WAILED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 RBERGIASS [-]4 STEEL CLAD W/FIBERGLASS RENFORCED PIAS TIC 9.TANK F-15 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑81DD%METHANOL COMPATIBLE FRP ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ C.INTERIOR 1 RUBBER LINED ❑2 ALKYD UNING ❑3 EPDXY UNING ❑4 PHENOLIC LINING LINING ❑ 5 GLASS UNING M<U�NUNED ❑95 UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO THER f D. CORROSION ❑ I POLYETHLENEWRAP ❑2 TARONASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE D*�UNKNOWN ❑99 OTHER IV. PIPING INFORMAAPN CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,130TH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTgUCTION U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE C. MATERIAL A U S ALUMINUM A6 CONCRETE A U I STEELCLADW/FRP A U B 1 OD%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A 1Y95 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 5 1 VISUAL CHECK S 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS / P 6 PRECISION TESTIN P S T PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P 8 99 OTHER VI INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIM TED OUANTITY OF 3. WAS TA FILLED WITH U A E REMAINING IN f1ALLON8 IN RT T flIAL7 ❑YES ❑ NO .449 1 THIS FOR HAS BEEN COMPLETED UNDER PENALfY OF PERJURY,AND TO THE BEST OF MY KNOWL DGE,IS TRUE AND CORRECT. APPLICANTS NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# lo D I l /s0 DO 11 1 iCURRENT LOCAL AGENCY FACILITY 10# APPROyEp pY NAME PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE RMR PIRA ON DATE CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE RECEIPT# BY: FDRMB(6-29-88) THIS FORM MUST BE ACCOMPANIEMAFACILITY/SITEAPPLICATION, FORM 'A',UNLESS A RT FORMA' HASBEENFILED L DATA PROCESSING COPY