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STATE OF CALIFC�7NIA WATER RESOURCES Cl�'IITRUL MUARU FORM S% UNDERGROUND STORAGE TAI I> 'PROGRAM TANK PERMIT APPLICATION INFORMATION TANK COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. L J MARK ONLY F-11 NEW PERMIT ❑3 RENEWAL PERMIT E]5 CHANGE OF INFORMATION ❑7 P NENTLY CLOSED TANK RMIT El 6 TEMPORARY TANK CLOSURE TANK REMOVED ONE ITEM ❑2 INTERIM PERMIT ❑1 AMENDED PEIll FARM TANK-YES E] NO �J FACILITY/SITE NAME WHERE TANK 18 INSTALLED: 1. RQYEAR DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-80 SPECIFY B. MANUFACTURED 8Y: ERS TANK IDM 2D D. TANK CAPACITY IN GALLONS: INSTALLED 11. TANK C NTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. J B LFAO C. ❑ 1 UNLEADED 2 ED ❑3 DIESEL A. 1 MOTOR VEHICLE FUEL F]2 PETROLEUM ❑ 1 PJET❑ RODUCT ❑+OASAHOL ❑5� FUEL ❑6 AVIATION GAS 3 CHEMICAL PRODUCT 4 OIL ❑ ❑95 UNKNOWN ❑2 WASTE ❑7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM 0,BELOW) El 5 HAZARDOUS BO EMPTY J D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF / A C.A.S.N: HAZARDOUS SUBSTANCE STORED A C.A.S.k 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.B,C,NI,D WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN A.TYPE OF ❑99 OTHER ! SYSTEM 2 SINGLE WAILED ❑/SECONDARY CONTAINMENT J STEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑/STEEL CLAD W/RBERGLASS REINFORCED PLASTIC B.TANK ❑5 CONCRETE ❑6 POLYVINYL CHLORIDE ❑7 ALUMINUM ❑8 100%METHANOL COMPATIBLE FFA MATERIAL ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑ss OTHER ❑ 1 RUBBER LINED ❑�eS LINING ❑3 EPDXY LINING ❑/PHENOLICLINING C.INTERIOR 5 GLASSLI ANO NLINED ❑95 LI LINING ❑IS LINING MATERIAL COMPATIBLE WITH 10091 METHANOL? ❑YES ❑NO OTHER D.CORROSION ❑ I POIYETFLENEWRAP AR OR ASPHALT ❑3 VINYL WRAP ❑/FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN -]99 OTHER '— IV. PIPING INFORMAT ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND.BOTH IF APPLICABLE A SYSTEM TYPE A SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER B CONSTRUCTION (PVC) U SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 85 UNKNOWN A U 99 OTHER (PVC) A U 8 FIBERGLASS PIPE A 91 NONE A U 1-STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE C.MATERIAL A U ALUMINUM A U 8 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 10091.METHANOL COMPATIBLE FRP A GALVANIZED STEEL A U 95 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. t p 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 1 ELECTRONIC MONITOR P 6 5 GROUNDWATER MONITORING WELLS �L!V P 8 8 PRECISION TESTING P 8 7 PRESSURE TESTING 91 NONE P 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 2.ESI IMAT D QUANTITY OF 3.W TANK FILLED WITH 1.ESTIMATED DAT LAST USED(MO/YR) SUS REMAINING IN MATERIAL? ❑YES ❑NO GALLONS ` THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KN LEDGE,IS TRUE AND CORRECT. DATE APPLICANT'S NAME(PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY COUNTY U JURISDICTION 11 AGENCY 11 FACILITY ID 9 TANK ID 0 EIRIU is / q � G baR3 APPR VEp a NAj1E r PHONE WITH AREA CODE CUR NT LEOCAL AGE CY FACILITY IDA (// {/J_ G J PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK I PERMR AMOUNT SURCHARGE AMT. REE CODE RECEIPT• BY: tiJ Y FORM a(S-29-SS) THIS FORM MUST BE ACCOMPANIED Of A FACILITY/SITE APPLICATION, FORM'A',UNLESS A WARENT FORMA' HAS BEEN FILED nATA PROCESSING COPY