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STATE OF CALIFORNIA* WATER RESOURCES CONTRO ARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM =� o <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPL E A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED TANK <br /> ONE ITEM El 2 INTERIM PERMIT F-1 4 AMENDED PERMIT El 6 TEMPORARY TANK CLOSURE 8 TANK REMOVEDFal 7 <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: FARM TANK-YES❑ NO (� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# 3 B. MANUFACTURED BY: W <br /> C. YEAR INSTALLED t/`f U D. TANK CAPACITY IN GALLONS: <br /> II. TANK C99fENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,CO LETE ITEM D. <br /> A. MOTOR VEHICLE FUEL F-1 2 PETROLEUM C. 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT F-] B.4 OIL PRODUCT 4 GASAHOL 5 JET FUEL 6 AVIATION GAS <br /> ❑ 5 HAZARDOUS D 80 EMPTY 0 95 UNKNOWN 2 WASTE 7 METHANOL 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 /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ 1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM SINGLE W LED [::]4 SECONDARY CONTAINMENT 99 OTHER <br /> STEEL/IRON F-] 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLADW/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK 5 CONCRETE E]6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 100%METHANOL COMPATIBLE FRP <br /> MATERIAL <br /> 9 BRONZE 10 GALVANIZED STEEL 0 95 UNKNOWN 99 OTHER <br /> C. INTERIOR 1 RUBBER LINED 2 ALKYD LINING F-] 3 EPDXY LINING 4 PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING ffi-6-UNLINED 95 UNKNOWN / <br /> El IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO E�KOTHER l <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP F-] 2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [::] 5 CATHODIC PROTECTION NONE ❑ 95 UNKNOWN E] 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 0 PRESSURE A U 3 GRAVITY A U 91 NONE A U 95 UNKNOWN A U 99 OTHER <br /> 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 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASS PIPE A U 91 NONE <br /> C. MATERIAL A U 5 ALUMINUM 6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL 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 MUST BE CIRCLED. <br /> �01 <br /> P 1 VISUAL CHECK 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P PRECISION TESTING S 7 PRESSURE TESTING P S 91 NONE P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED( O/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? [:]YES � NO <br /> O✓ <br /> THIS FORM HAS BE N 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 /> COUrnNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# <br /> I � I � I I 1 1 -1 E[ F-1 I I J 1 L I I � <br /> CURRENT LOCAL AGENCY FACILITY ID APPROVED BY NAM HONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPR VAL D E PERM EXPIRATIO ATE <br /> CHECK# PERMIT AMOUNT SURCHARGE A T. FEE CODE RECEIPT# BY: <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS RRENT FORM'A' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />