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INS STATE OF CALIFORNI, WATER RESOURCES CONTRdWARD FORM 'S': UNDERGROUND STORAGE TANK PROGRAM ' TANK TANK PERMIT APPLICATION INFORMATION R�� COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. Vi o MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 4 7 PERMANENTLY C�pSEO-TPNK 10 Z ONE ITEM 2 INTERIM PERMIT ❑1 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED/(%9/ FACILITY/SITE NAME WHERE TANK IS INSTALLED: /,-y 6 _ RM TANK-YES❑ NO aT (V 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY %rte GCD A. OWNERS TANK ID MC.D R. MANUFACTURED BY: i ([� C. YEAR INSTALLED D. TANK CAPACITY IN GALLONS: / �6% II. TANK CONTENTS IF(A1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. EAM 1 MOTOR VEHICLE FUEL ❑2 PETROLEUM B. C. ❑ I UNLEADED 2 LEADED ❑3 DIESEL 3 CHEMICAL PRODUCT ❑ 1 OIL [4iI PRODUCT ❑1 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS 5 HAZARDOUS 80 EMPTY ❑95WASTE ❑ 7 METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) OT MOTOR VEHICLE FUEL,ENTER NAME OFARDOUS SUBSTANCE STORED&C.A.S.6 C.A.S.N: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA ❑ 95 UNKNOWN SYSTEM E]2 SINGLE WALLED El 1 SECONDARY CONTAINMENT El 99 OTHER B.TANK Ell STEEUIRON ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 1 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 C019DETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B I00%METHANOLCOMPATIBLEFRP ❑ B BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑99 OTHER C.INTERIOR ❑ I RUBBERUNED ❑2 AL%YD LINING ❑3 EPDXY LINING ❑1 PHENOLIC LINING LINING ❑5 GIASSUMNG ❑6 UNLINED ❑9UNKN ❑ ISUNINGWTERIALCOMPATIBLEWITHIOD%METFWX)L7 YES 0N OWN 95 5 UNKNOWN D.CORROSION ❑ 1 POLYETHENEWNAP E]2 TNIORASPHALT 3 VINYL WRAP 1 FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE nMATERIAL A U 1 SUCTION A U 2 PRESSURE VITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 37!"" 91 NONE A U 95 UNKNOWN A U 99 OTHER A U I STEEL/IRON A U 2 STAINLESS STEEL A U 3VC) A U i FIBERGLASS PIPE A U 91 NONE A U 5 ALUMINUM A U 6 CONCRETE A U 7A U B GALVANIZED STEEL A U 95 UNKNOWN A U B 10096 METHANOL COMPATIBLE FRPA U 9 V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. t t VISUAL CHECK P t 2 INVENTORY RECONCILIATION P t 3 VADOSE WELLS P 5 / ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS P 6 6 PRECISION TESTING P 6 7 PRESSURE TESTING P 6 91 NONE P B 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1.ESTIMATED PATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF SUBSTANCE REMAINING IN 3. WAS TANK FILLED WITH GALLONS INERT MATERIALS YES [] 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY 6 JURISDICTION Y m � AGENCY•n FACILITY IDM TANK ID M CURRENT LOCAL AGENCY FACIL)TY ID 6 V APPROVED BY NAME PHONES WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE ,/Yy CHECKI PERMITAYOUNT &gCNARGE AMT. FEE CODE 'EIPT I BY: FORM B(8-26-88) THIS FORM MUST BE ACCOMPANIED BYAFACIUTY/$LTE AP PLICATION FORM 'A' UNLESSACURRENT FORMA' HAS RFFN cu an n