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*TATE OF-CALIFORNIA WATER RESOURCES CONTROL BOARD ��. <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> _.T/�� TANK PERMIT APPLICATION INFORMATION ' <br /> 6., sia <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. z <br /> f0 <br /> MARK ONLY ❑ 1 NEW PERMIT F__j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ;7,PEAMANENTLY CLOSED T K <br /> ONE ITEME]2 INTERIM PERMIT E3 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE TANK REMOVED I D <br /> N <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: �� FARM TANK-YES[:] NO (n <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY 1"a <br /> 00 <br /> A. OWNERS TANK ID# B. MANUFACTURED BY: N <br /> C.YEAR INSTALLED A000D. TANK CAPACITY IN GALLONS: <br /> 11. TANK CONTENTS IF(A-1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. F_� 1 MOTOR VEHICLE FUEL 2 PETROLEUM B. C. 1 UNLEADED [::]2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 OIL F 1 PRODUCT 4 GASAHOL E:] 5 JET FUEL 6 AVIATION GAS <br /> Ej 5 HAZARDOUS 80 EMPTY [:]95 UNKNOWN [::]2 WASTE 11 7 METHANOL Ej 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.#: <br /> 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A.8,C.&D <br /> A.TYPE OF Q I DOUBLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED [:]4 SECONDARY CONTAINMENT E]99 OTHER <br /> Q I STEEUIRON �2 STAINLESS STEEL F-13 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> MMATERIAL �5 CONCRETE F_�6 POLYVINYLCHLORIDE 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> El 9 BRONZE [j 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED E]2 ALKYD LINING �3 EPDXY LINING 4 PHENOUC UNING <br /> C.INTERIOR <br /> IN NRG R F_�5 GLASS LINING F-1 6 UNUNED 95 UNKNOWN � <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES NO 99 OTHERy/ , \ <br /> D.CORROSION ❑ I POLYETHLENE WRAP ❑2 TAR OR ASPHALT r__j 3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION [:]91 NONE 95 UNKNOWN Ej 99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> 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 <br /> 0.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 <br /> A U 1 STEELARON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 9/ NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8100%METHANOL COMPATIBLE FRP <br /> r' A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM!BUST BE CIRCLED. <br /> P S I VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 8 3 VADOSE WELLS P 8 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P 8 95 UNKNOWN P 8 99 OTHER <br /> V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1.ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED QUANTITY OF 1 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? YES NO <br /> GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> OTC CI I 16lr)lo ' -'Rl <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED <br /> BY NAME�]�� PHONE 8 WITH AREA CODE <br /> 3 <br /> PERMIT NUM R PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. j7ii7cODE RECEIPT# BY: <br /> J. FORMB(6-29-w) THIS FORIA MUST BE ACCOMPANIE A FACILITY/SITE APPLICATION, FORM 'A',UNLESS,,:-!. RENT FORWR HAS BEEN FILED <br /> DATA PROCESSING COPY <br />