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ATE OF CALIFORNIA* WATER RESOURCES CONTROLdVRD 4; UNDERGROUND STORAGE TANK PROGRAM TION �° �,. ° FORM 'S': TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ""°'' L1 5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK 1:13 RENEWAL PERMIT ❑8 TANK REMOVED i5 MARK ONLY El1 NEW PERMIT ❑q AMENDED IT ❑6 TEMPORARY TANK CLOSURE N ONE ITEM F-1 2 INTERIM PERMIT PERM1 FARM TANK-YES❑ NO 4b► FACILITY/SITE NAME WHERE TANK IS INSTALLED: W I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPE CIFY IIFYUFACTURED BY: �� A. OWNERS TANK IDR (iti TANK CAPACITY IN GALLONS: C.YEAR INSTALLED 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARK B. D COMPLETE ITS Z LEADED❑3 DIESEL A. ❑1 MOTOR VEHICLE FUEL E] 2 PETROLEUM ❑ 1 PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑3 CHEMICAL PRODUCT ri; 011- WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) F-15 HAZARDOUS E] 80 EMPTY ❑95UNKNOWN /-� LE FUE ,ENTER NAME (,v 0's 2i V " l C.A.S.R: Oc7 D. IF NOT MOTOR VEHI LE FUE HAZARDOUS SUBSTANCE STORED&C.A.S.ROF Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D ❑95 UNKNOWN ❑1 DOUBLEWAU.FD ❑3 SINGLEWALLED WITH EXTERIOR LINER A TYPE OF ❑99 OTHER SYSTEM SINGLEWALLED ❑4 SECONDARY COMAINMENT ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEELCIADWIFlBERGIASS REINf-0RCED PLASTIC UIRON 8 10096 METHANOL COMPATIBLE FRP S.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑7 ALUMINUM ❑ MATERIAL ❑9 BRONZE ❑ 10 GALVANIZPSTEEL ❑95 UNKNOWN ❑99 OTHER ❑1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING q PHENOLIC LINING C. INTERIOR ❑5 GLASS LINING ❑6 UNLINED_ LINING ❑5 LINING WINGMATEALCOMPATIBLE WRH 10096 METHANOL? ❑YES ❑NO ❑99 OTHER ❑ 3 VIWl-WRAP E]4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ I POLYETHLENEWRAP ❑2 TARORASPHALT ONE ❑gg OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑91 N UNKNOWN IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLIC�ABN NE A U 95 uNKNOwN A U 990THER A SYSTEM TYPE A u 1 sucrloN A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U 91 NONE A U 95 UNKNOWN A U 99 OTE A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYLCHLORIDE(PVC) A U 4 FIBS10DMETHANOL COMPAGLASS PIPE A UIBLE FRP 91 C. MATERIAL A U S ALUMINUM A U fi CONCRETE A U 99 OTHER W/FRP A U 9 GALVANIZED STEEL A 95 UNKNOWN V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. p 3 1VISUALCHECK P S 21NVENTO0 S 95 UNKNOWN P 8 99 OTHER RYRECONCIUATION P S 31VNONEEWELLS P S 4 ELECTRONICMONITOR P 8 5 GROUNDWATER MONITORING WELL P S 6 PRECISION TESTING P S 7 PRESSURETESTING VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3.WAS TANK FILLED WITH 2.ESTIMATED QUANTITY OF INERT MATERIAL? ❑YES ❑NO 1, Es 1MATED DATE LAST USED(MO/YR) SUBSTANCE REMAINING IN GALLONS THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY TANK ID# FACILITY ID R COUNTY R JURISDICTION N AGENCY R o APPROVED BY NAME PHONE N WITH AREA CODE F CURREN LOCAL GENCY FACILITY IDN / ^ ^ do • — PERMIT APPROVAL DATE RMITT EXPIRATION DATE PERMIT NUMBER RECEIPT# BY: CMECK N PERMIT AMOUNT S RCHARGE AMT. FEE CODE V FORMB(6-2s-e6) THIS FORM MUST BE ACCOMPANI ILmUATAPPROCON,PROCESSINGCOPY A',UNLESS ...TRENT FORMA' HAS BEEN FILED /