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STATE OF•CALIFORNI,,_ WATER RESOURCES CONTR"BOARD FORM 'S'' , --UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION . , , ,,• .,! COMPLETE A SEPARATE FORM WITH THE FOL5OWINq.H4iFORMATIoN FOR EACH TANK •^ •• z I MARK ONLY ?�-❑ I NEW PERMIT.. ❑D RENEWAL PERMIT Zr5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED TAN 1 ONE ITEM ,-� t; ❑t INTERIM PEIWR ❑1 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: 6FARM TANK•YES M NO TV I. TANKDESCRIPTION COMPLETE ALL ITEMS UNKNOWN-60 SPECIFY "Otlb A OWNERS TANK ID I AAP B. MANUFACTURED BY: u ED C.YEAR INSTALLED S' D. TANK CAPACITY IN GALLONS: If. TANK CONTENTS IF(A.1),18 RAKED,COMPLETE ITEM C.IF(JAL.1),j S NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ ETROLEUM B. C. ❑ 1 UNLEADED ❑FS: FUFJL ❑ 0 DIESEL ❑ 3 CHEMICAL PRODUCT [Er4 OIL T pflppUCT ❑K GASAHOL ❑ ❑6AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ T METHANOL (DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF nnp' HAZARDOUS SUBSTANCE STORED 3 CAS.I ' "1� 0,-( CAS.9: o p III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BORA.B.C.&0 A.TYPE Of ❑IODUBIFWULED ❑ 3SINGLE WALIEGMTHEIERORUNER r7 95 UNKNOWN SYSTEM ❑2 SINGLE WAILED ❑4 SECONDARYCONTXNMENT ❑99 OTHER F7 STEEURDN ❑2 STAIWMSTEEL ❑0 FKAGIASS ❑1 STEEL GADW ASFAGLASS REV*ORCED FUSTIC B TANK MATEflW. �❑5CON RETE 6 POLYIIW%METO.COMPATIBLFFRP - .. ❑ VWSLO ❑EORDE 7AMINM ILW ❑ ❑ 9 BflONZE - 0 10 GALVANIZED STEEL ❑95 UNKNOWN 99 OTHER .' C.INTERIOR'. :•,.❑ I RUBBER UNED . .. ❑2 ALM LNINO ❑0 EPWUUNO ❑ I PLENOLICUNNG LINING,, ;'.. ❑ S GLASSLWLNO ❑ 6 LWUNED ❑ 95 UNKNOWN - ;❑ B UNINO MATERMLCOMPATI MILE MTH ICA METHANOL? ❑YES ❑NO ❑ 99 OTHER D.CORROSION ❑ I.POLYETHLENEWRAP . ❑2 TAR OR ASPHALT ❑2 VVNLWRAP ❑I FDBIGUMIKINFORCEDMASTIC PROTECTION. ❑5 CATLODICPNDTECTW ❑91 NONE ❑95 UIf1AWA1 ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE - A U 1 SUCTION A U 2 PRESSURE A U 0 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U i SINGLE WALLED A U 2 DOUBLE WALLED A U 0 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 STEELAIRON A U 2 STAINLESSSTEEL A U S POLYVINYL CHLORIDE(PVC) A U I FIBERGLASS PIPE A U 91 NONE C.MATERIAL_. A U 5 ALUMINUM A V 9 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A V 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 I 1 VISUAL CHECK P • 2 INVENTORY RECONCILIATION P I 0 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P / 5 GROUND WATER MONITORING WELLS P S I PRECISION TESTING P I T PRESSURE TESTING P % 91 NONE P I 95 UNKNOWN P I 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED DATE LAST USED(MONA) 2. ESTIMATED QUANTITY OF 0.WAS TANK FILLED WITH ' SUBSTANCE REMNNINO IN GALLONS INERT MATERIAL? YES NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# ' , '.JURISDICTION I AGENCY I FACILITY ID I TANK ID E CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAYS PHONE E WITH AREA CODE oo (--slJ� ►ERYIT NUYIFA ►ERYR APPROVAL GATE PEpYIT EXPIRATION DATE CHECKS PERYITAMOUNT 9URCHARGE"T. FEE COOL ECLIPTI B7: 71 5- •� FoRMO(I.29•5a) THIS FORM MUST BE ACCOMPANIED BY A FACIUTY/SITE APPLICATION, FORM 'A'.UNLESS A CURRENT rORMY' Hacnrrurua .