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STATE OF CALIFORN' WATER RESOURCES CONTRL,_ BOARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. .: MARK;ONLY ❑ 1 NEW PERMIT ❑3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 RMANENTLY CLOSED TANK ONE ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE❑ B TANK REMOVED FACILITME WHERE TANK IS INSTALLED: FARM TANK-YES NO ❑ C-n N I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY W A. OWNERS TANK ID# F� 7./ B. MANUFACTURED BY: C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: SW II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),18 NOT MARKED,COMPLETE ITEM D. A 1 MOTORVEHI T FUEL -12 PETROLEUM B. C. ❑ 1 UNLEADED lQ` LEADED ❑3 DIESEL ❑3 CHEMICAL PRODUCT ❑4 OIL 1 PRODUCT 4 GASAHOL 5 JET FUEL ❑ ❑ ❑6 AVIATION GAS ❑5 HAZARDOUS ❑BO 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.C.A.S.# - A CAS #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,a D A TYPE OF LUL;PUBLEWALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN SYSTEM 2PNGLE WALLED ❑4 SEGONDARYCONTAINMENT ❑99 OTHER En 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED KWIC B.MATTERIAL ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑8 ImmErHANOLOOMPATIBLEARP ❑9 BRONZE ❑10 GALVANIZEDSTEEL ❑95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑2,4MUNING ❑3 EPDXY LINING ❑4 PHENOUC UNING LINING ❑S GLASS LINING 6 UNLINED ❑S5 WN F-1ISLINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO 9907HER D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TM OR ASPHALT ❑3 WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE 5 UNKNOWN A U 99 OTHER B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5ALUMINUM AAA U 7STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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. o P 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURETESTING R 91 ONE P S 95 UNKNOWN P B 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMA ED DATE LAST USED(MO/YR) Z.ESTIMAT)b QUANTITY OF3. WAST K FILLED WITH SIJBSJ 011LLON8 REMAINING IN - IN RIAL? E]YES ❑ NO /1/ THIS FORM HAS 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# 1,0 10 1 qldo I o CURRENT LOCAL AGENCI'FACT IU Y ' APPROVED BY NAME PHONE#WITH AREA CODE S /lv J(J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK K PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORMS(6-29-88) THIS FORM MUST BE ACCOMPANIEnY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMAHAS BEEN FILED