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STATE OF CALIFORNIA WATER RESOURCES CONTRO ARD FORM 'S': UNDE GROUND STORAGE TANK PRO AM TANK TANK PERMIT APPLICATION INFORMATION a COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Y MARK ONLY ❑ I NEW PERMIT 0 3 RENEWAL PERMIT fQCLOSED ONE ITEM ❑5 CHANGE OF INFORMATION ❑7 PERMAI �2 INTERIM PERMIT 04 AMENDED PERMIT6 TEMPORARY TANK CLOS RE 8 TANK RFACILITY/SITE NAME WHERE TANK IS INSTALLED:I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— FARM TANK- C� A. OWNERS TANK ID# SO SPECIFY .O B. MANUFACTURED BY: U'I C. YEAR INSTALLED �y 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 VEHICLE FUEL E]2 PETROLEUM 3 CHEMICAL PRODUCT � 4 OIL B. C' ❑ 1 UNLEADED 0 2 LEADED 0 3 DIESEL El 80 EMPTY 95 UNKNOWN 1 PRODUCT 4 GASAHOL 5 JET FUEL E] 6 AVIATION GAS 5 HAZARDOUS 0 2 WASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D C A.S.#: A TYPE OF ❑ 1 DOUBLE WALLED L_j 3 SINGLE WALLED WITH EXTERIOR LINER SYSTEM 0 2 SINGLE WALLED11 ❑95 UNKNOWN 4 SECONDARY CONTAINMENT E]gg OTHER B.TANK ❑ I STEEL/IRON 11 2 STAINLESSSTEEL MATERIAL 6 POLYVINYL CHLORIDE ❑7 ALUMINUM ERGLASS 0 4 STEE100% CLAD METHANOLIBERGLA IBLREINFORCED PLASTIC 5 CONCRETE 0 ❑ 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 0 B 10096 METHANOL COMPATIBLE FRP 99 OTHER C. INTERIOR ❑ I RUBBER LINED 2ALKYO LINING LINING ❑5 GLASS LINING � ❑3 EPDXY LINING 0 4 PHENOLIC LINING 6 UNLINED 0 95 UNKNOWN IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL' YES NO E]gg OTHER D. CORROSION ❑ I POLYETHLENEWRAP 2 TARORASPHALT PROTECTION 3 VINYL Wggp q FIBERGLASS REINFORCED PLASTIC 5 CATHODIC PROTECTION 91 NONE F-1 95 UNKNOWN —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 B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE 91 NONE A U 95 UNKNOWN A U 99 OTHER WgLLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U ISTEEL/IRON A U 2 STAINLESSSTEEL A C. MATERIAL A U 5 ALUMINUM U 3 POLYVINYL CHLORIDE(PVC) A U 4 1FIBERGLASS 00%METHAN L A TI 91 NONE A U 6 CONCRETE A U 1 STEEL CLAD W/FRP A U 9GALVANIZED STEEL A U 95 UNKNOWN A U 8100%METHANOL COMPATIBLE FRP A U 9g OTHER V. 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 S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S y ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 3 6 PRECISION TESTING P S 7 PRESSURE TESTING P 3 91 NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s ss OTHER 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMUBSTAATED QUANTITYG I SNCE REMAINING N 3. WAS TANK FILLED WITH GALLONS INERT MATERIAL? YES 0 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY M CILIA`/------` TANK ID k CURq LO AL AGENCY FACILITY ID# 3 PRO PHONE#WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNTz 3� SURCHARGE AMT. FEE CODE RECEIPTk B FORM a(s-2s-ee) THIS FORM MUST BE ACCOMPAN L BY FACILITY/SITE APPLICATION, FORM 'A'.UNLESS .__ -11 CYT rne..,., ..._