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WATER RESOURCES CONTRO ARD STATE OF CALIFORNIA W. UNDE ROUND STORAGE TANK PRO AM m .6 FORM 'S" TANK PERMIT APPLICATION INFORMATION TANK L/ COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH' 10 z 5 CHANGE OF INFORMATION 1:17 PERMANENTLY CLOSED TANK MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT CLOSURE ❑B TANK REMOVED ❑4 AMENDEDPERMIT ❑6 TEMPORARY TANK W ONE ITEM F-12 INTERIM PERMIT r FppM TANK•YES❑ NO (�,� FACILITY/SITE NAME WHERE TANK IS INSTALLED: J I. TANK DESCRIPTION C MPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY B. MANUFACTURED BY: A. OWNERS TANK ID# D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED 11, TANK CONTENTS IF(AM,IS MARKED,COMPLETE ITEM C.IF(A.1I,IS NOT MAR B. COMPLETE ITS D. LEADED ❑ 3 DIESEL B. A. ❑ 1 MOTOR VEHICLE FUEL 0 ROLEUM ❑ T ODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT L 4 OIL 7 METHANOL Ir/LBg/OTHER(DESCRIBE IN ITEM D,BELOW) ❑5 HAZARDOUS ❑ 60 EMPTY ❑95 UNKNOWN 2 WASTE ❑ 'ice 11 D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF ///_ m'/ C.A.S.#: HAZARDOUS SUBSTANCE STORED&G.A.S.# 'g' Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,s D DOUBLEWALLED 3SINGLEWALLED WITH EKTERIOR LINER ❑95 UNKNOWN A. TYPE OF 4 SECONDARY CONTAINMENT ❑99 OTHFA SYSTEM V2 SINGLE WALLED ❑ ❑ 1 STEELIIRON ❑2 STAINLESS STEEL ❑ 3 RBERGLASS ❑4 STEEL CLAD WIRBERGLASS REINFORCED PLASTIC B.TANK ❑ 5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 UMINUM ❑8100%METHANOL COMPATIBLE FRP MATERIAL ❑9 BRONZE ❑10 GALVANIZED STEEL 95 UNKNOWN ❑99 OTHER F-1 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING 4fMENOUC LINING C. INTERIOR ❑5 GLASS UNING ❑6 UNUNED LEK995 UNKNOWN LINING ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑ NO ❑99 OTHER 1 POLYETHLENE WRAP ❑2TAR OR ASPHALT ❑ WLWRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC 0. CORROSION ❑ ❑ PROTECTION ❑5 CATHODIC PROTECTION E]91 NONE 95 UNKNOWN 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 3 GRAVITY A U 91 NONE A U 95 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 A 95 UNKNOWN A U 99 OTHER A 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 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLAD W/FRP A U S 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 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 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS 6-,1 S PRECISION TESTI S 7 PRESSURETESTING P S 91 NONE P 8 95 UNKNOWN P S 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF INERT MATERIAL? [:]YES [] NO SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY FACILITY ID# TAFAIEACOD9E RMB16-29-8s) JURISDICTION AGE NCY FACILITY I APPROVED BOY NAME' � 5� PHONE N WI� M PERMIT APPROVAL DATE PERMIT EXPIRATION DATE BY: / 1� / PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT N C V/ FORM MUST BE ACCOMPANIED BYAFACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HASBEENFILED _ DATA PROCESSING COPY