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STATE OF CALIFORNIA WATER RESOURCESCONTROI BOARD FORM 'S': UNDERGROUND STORAGE TANK PROtvAAM ' TANKTANK PERMIT APPLICATION INFORMATION d6fAPLEtE A WAIIATE FORM WITH THE FOLLOWING INFORMATION FON EACH TANK. MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY COS ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE 8 TANK REMOVE O FACILITY/8I1E NAME WHERE TANK IS INSTALLED:, 3 / S p CSO RM TANK-YES NO I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY ` A. OWNERS TANK ID q 2 1 B. MANUFACTURED BY: C. YEAR INSTALLED 0. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A•9,IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM 8. C. ❑ 1 UNLEADED ❑2 LEADED ❑ 3 DIESEL ❑3 CHEMICAL PRODUCT ❑ 4 OIL ❑ 1 PRODUCT ❑<GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑5 HAZARDOUS ❑80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL.ENTER NAME OF HAZARDOUS SUBSTANCE STORED&CAS.X C.A.S.Y: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOK A,B,C,S D A TYPE OF ❑i DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINEA ❑95 UNKNOWN SYSTEM ❑2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER ❑ 1 STEEUIRON ❑2 STAINLESSSTEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC I.TANK F-1 5 CONCRETE ❑8 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑ B 10D%METHANOL COMPATIBLE RHP MATERIAL s❑9 BRONZE ❑ ID GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER ❑ 1 RIBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING C.LININGIOR ❑5 GLASS LINING ❑B UNLINED ❑95 UNKNOWN ❑IS LINING MATERIAL COMPATIBLE WITH IW%METHANOL? ❑YES ❑NO ❑99 OTHER D.CORROSION ❑ 1 POLYETH(ENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHMIC PROTECTION ❑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 U 95 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 F18EAGLASSPIPE A U 91 NONE C.MATERIAL A U 5 ALUMINUM A U 0 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%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 $ FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. O B 1VISUAL CHECK P 6 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 6 5 GROUND WATER MONITORING WELLS P 8 6 PRE CISION TESTING 11 8 7 PRESSURE TESTING P S 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE I.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES E]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 A SIGNATURE) DATE t LOCAL AGENCY USE ONLY COUrnR NTY JURISDICTIONS AGENCY A FACILITY ID F TANK ID R CURRENT LOCAL AGENCY FACILITY ID J APPROVED BY NAME PHONE 4 WRN AREA CODE (HOU Z /7 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE tom/ CHECK O PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT P BY: 3' Z i9d FORM B(6-29-88) THIS FORM MUST BE ACCOMPAN r A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A'DCARERT FORMA' HAS BEEN FlLED DATA PROCESSING COPY