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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION :, COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. la MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7,PERMANENTLY CLOSED o. K ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED FACILITY/SITE NAME WHERE TANK IS INSTALLED• �' FARM TANK-YES NO ❑ Z I. TANK DESCRIPTION COMPLETE ALL ITEMS IF UNKNOWN-SO SPECIFY 10 A. OWNERS TANK ID# litB. MANUFACTURED BY: C.YEAR INSTALLED D. TANK CAPACITY IN GALLONS: W 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. --4 A. 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM �B.- C. ❑ 1 UNLEADED ❑ 2 LEADED 3 DIESEL Um ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL Ie I 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 '� HAZARDOUS SUBSTANCE STORED 8( A C.A.S.#: All. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A.TYPE OF ❑ 1 DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR UNEA ❑95 UNKNOWN SYSTEM V2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER 11 STEBUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER C. INTERIOR F-11 RUBBER UNED [-]2 ALKYD UNING ❑3 EPDXY LINING ❑4 PHENOLIC UNING LINING ❑5 GLASS LINING 06 UNLINED ❑95 UNKNOWN ❑ IS UNING MATERIAL Comm WITH 10096 METHANOL? ❑YES ❑ NO ❑99 OTHER D. CORROSION ❑ I POLYETHLENE WRAP ❑2 TM OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PMSRC PROTECTION ❑5 CATHODIC PROTECTION a91 NONE ❑95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION AU 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH 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 C. MATERIAL A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER �.y. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P B S GROUND WATER MONITORING WELLS ' P 5 6 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P 8 95 UNKNOWN P S 99 OTHER r�VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE T USED(MO/YR) 2 ESTIMATED UANTITY OF 3.WAS T FILLED WITH SUBS MAINING IN IN IAL? ❑YES ❑NO GALLONS THIS FORM HA 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# JURISDICTION# AGENCY# FACILITY ID# TANK ID# O Z UU 10 11 CURRENT LOCAL AGENCY FACILITY ID# APPR VEO N ME PHONE#WITH AREA CODE 2� PERMIT NUMBER PERMIT APPROVAL OA PERMIT EXPIRATION DATE 1 CHECK# PERMIT AMOUNT SURCHARGEAMT. FEE CODE �JLEcEIPr* BY: FORM B 13-7-BBI THIS FORM MUST BE ACCOMPANI Y A FACILITY/SITE APPLICATION, FORM 'A',UNLESS MRRENT FORMA' HAS BEEN FILED DATA PROCESSING COPY