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STATE OF CALIFORNIO WATER RESOURCES CONTRCOARD Q 'r,^ UNDERGROUND STORAGE TANK PROGRAM FORM 'S': INFORMATION TANK TANK PERMIT APPLICATION INF Z COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. I O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑7 PERMANENTLY CLOSED TANK MARK ONLY ❑ ❑6 TEMPORARY TANK CLOSURE ❑B TANK REMOVED (V ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT FAllz RM TANK-YES E] NO JIB.FACILITY/SITE NAME WHERE TANK IS INSTALLED: a (7) cn I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO 11 SPECIFY (� B. MANUFACTURED BY: ui A. OWNERS TANK ID N (rC/ D. TANK CAPACITY IN GALLONS: C.YEAR INSTALLED �� II. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM 2 B. LEADED 3 DIESEL A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 4 GASAHOL ❑5 JET FUEL ❑ 6 AVIATION GAS ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) ❑ 5 HAZARDOUS El 80 EMPTY 0 95 UNKNOWN E]2 WASTE ❑7 METHANOL D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF C.A.S.N: HAZARDOUS SUBSTANCE STORED&C.A.S.X III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C.&O 3 SINGLE WALLEDWITH EKTERIOR UNER ❑95 UNKNOWN A TYPE OF ❑ 1 OOUBLEWAILED ❑ ❑ SYSTEM rawSNGLE WALLED ❑4 SECONDARY CONTAINMENT 99 OTHER STEEU010N ❑2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑4 STEELCUOWIFIBERGLASS REINFORCED FUSTIC B.TANK 5 CONCRETE 6 POLYVINYLCHLORIDE ❑7 ALUMINUM B 100%METHANOL COMPATIBLE FRP MATERIAL 9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN El 99 OTHER ❑ 1 RUBBERUNED E]2 ALKYO LINING ❑3 EPOKYLINING �ENOLIC NING ❑ C.INTERIOR F` 5 GLASS UNING ❑6 UNUNED y/ LINING L❑J IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES [-] NO �'9gOTHEfi I Jdn „ D.CORROSION ❑1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYLWAAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE UNKNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLIC�ABLE NONE A SUNKNOWN A U 99 OTHER A SYSTEH EMTYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A 5 UNKNOWN A U 99 OTH A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVG) A U 4 FIBERGLASS PIPE A U 91 NONE C.MATERIAL A U S ALUMINUM A 6 CONCRETE A U 7 STEEL CLAD W/FRP A U B 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL A U 5 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 8 4ELECTRONIC MONITOR P S 1VISUALCHECK P S 2 INVENTORY RECONCILIATION !_X,,,3 VADOSE WELLS P S 9B ROUND WATER MONITORING WELLS OTHER P S 6 PRECISION TESTING P S 7 PRESSURETESTING p g NONE P S 95 UNKNOWN VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 3 WAS TANK FILLED WITH 2.ESTIGALLONS MATED QUANTITY OF INERT MATERIAL? [:]YES ❑NO 1. ESTIMATED DATE LASTUSED(MO/VR) SUBSTANCE REMAINING IN 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) LOCAL AGENCY USE ONLY FACILITY ID$ TANK ID X FCHEC Y N JURISDICTION AGE O O APPA VE D BY NAXIFj�j PHONE N WITH AREA CODE AL AGENCY FACILITY I D X �9YK ER PERMIT APPROVAL DA PERMIT EXPIRATION DATE PERMIT AMOUNT SURCHARGE AMT. FEE CODE ECEIPT X BY: FORM B(6-29-8B) THIS FORM MUST BE ACCOMPANIED A FACILITY/SITE APPLICATION, PROCESSING 'A',UNLESS A CURRENT FORM'A' HAS SEEN FILED DATA