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STATE OF CALIFORNI* WATER RESOURCES CONTRON ARD <br /> FORM 'S': UNDE ROUND STORAGE TANK PROGIRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONI C- <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 7 ERMANENTLY CLOSED TANK <br /> 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED C?Q1 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: '' �7 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY / FARM TANK-YES NO CA) <br /> A. OWNERS TANK IDN Q B. MANUFACTURED BY <br /> C. YEAR INSTALLED <br /> D. TANK CAPACITY IN GALLONS: <br /> 11. TANK TENTS IF(A.1,.WMARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL �_ p PETROLEUM ❑ I UNLEADED 2 LEADED IESEL3 CHEMICAL PRODUCT q OIL PRODUCT KE 4 GASAHOL 5 JET FUEL 26 AVIATION GASEl 5 HAZARDOUS � 80 EMPTY �:U7jWASTE 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED 8 C.A.S.H Will <br /> it <br /> W�l C.A.S.p: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,8 D <br /> A. TYPE OF ❑ 1 WALLED 0 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM U11r,SING LLED E]4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> B. TANK I STEEL/IRON 2 STAINLESS STEEL E]3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE 6 POLYVINYLCHLORIDE 07 ALUMINUM 8 f00%MEIHANOL COMPATIBLE FRP <br /> 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> C.INTERIOR ❑ I RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING 4 PHENO LINING <br /> LINING ❑ 5 GLASS LINING 6 UNLINED L��.R,,rU/ <br /> NKNOWN <br /> 0ISLINING MATERIAL COMPATIBLEWITH100%METHANOL' YES 0 NO 99 OTHER <br /> D. CORROSION ❑ I POLYETHLENE WRAP QR ASPHALT 3 VINYL WRAP <br /> 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION E]5 CATHODIC PROTECTION 91 NONE <br /> 95 UNKNOWN gg OTHER <br /> IV. PIPING INFORMATI CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> Ec <br /> E u IN 1 suc q u z PRESSURE <br /> A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER, <br /> ION 1 SINGLE WALLED q U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> UM A u 6 CONCRETE <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 9 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P S I VISUAL CHECK P S 2 INVENTORY RECONCILIATION P SE WillP S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P S 6 PRECISION TESTING P S 7 PRESSURE TESTING S 91 NONE3 P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> L ESTIMATED DATE LAST USED( IF i : <br /> 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 3_ WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL' YES D NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED S SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> UNTY# <br /> 3`�--/-J JURISDICTION, <br /> � AGENCYN <br /> FACILITY IDN TANK ID N <br /> CURRENT LOCAL AGENCY FACILITY ID N O <br /> APPROVED BY NAME PHONE M WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE <br /> PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT URCHARGE AMT. <br /> 1 FEE CODE RECEIPT# <br /> 1`I Bi <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A RENT FORMA' HAS BEEN FIL <br /> DATA PROCESSING COPY <br />