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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> � � ,� TANK PERMIT APPLICATION INFORMATION �m <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL05EaJANK <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURETANK REMOVED (q C) <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: L1 L/ ��' /!u �/�,1'�iRM TANK-YES❑ NO <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> f <br /> A. OWNERS TANK ID# ,� B. MANUFACTURED BY: <br /> C.YEAR INSTALLED �% D. TANK CAPACITY IN GALLONS: "-o U <br /> 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. ❑ 1 MOTOR VEHICLE FUEL Ea,2 PETROLEUM B. C. ❑ 1 UNLEADED ❑ 2 LEADED ❑3 DIESEL <br /> ❑3 CHEMICAL PRODUCT L_J 4 OIL L ' PRODUCT ❑ 4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL V9 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF r �� /I \ C.A.S.#: -1/1/f <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# '� <br /> 110. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> A.TYPE OF ❑ BLE WALLED ❑3 SINGLE WALLED WITH EXTERIOR LINER ❑95 UNKNOWN <br /> SYSTEM 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑99 OTHER <br /> El 1 STEEL/IRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK ❑5 CONCRETE ❑6 POLYVINYLCHLORIDE ❑ 7 ALUMINUM ❑B 100%METHANOL COMPATIBLE FRP <br /> HATERIAL <br /> ❑9 BRONZE ❑ 10 GALVANIZED STEEL ❑95 UNKNOWN ❑99 OTHER <br /> ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING ❑4 PHENOLIC LINING <br /> C.LINING INTERIOR ❑5 GLASSUNING ❑6 UNLINED <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES ❑ NO �PNKNOWN <br /> THER <br /> D.CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑ 3 INYL WRAP El FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE 95 UNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMAT ION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A.SYSTEM TYPE A flUj 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A b95 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 95 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 A6 CONCRETE A U 7 STEEL CLAD W/FRP A U 8 100%METHANOL COMPATIBLE FRP <br /> 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 MUST BE CIRCLED. <br /> k- P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> i•� 1 ! P 'S 6 PRECISION TESTING P S 7 PRESSURE TESTING P 8 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(MO/YR) 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES EJ No <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 /> f <br /> ,' Qp = o17Dm <br /> 01 <br /> CU /CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 1. 11 Iq D c� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE II,. <br /> CHECK# PERMIT AMOUNT r SURCHARGE AMT. FEE CODE ECEIPT <br /> FORM B(6-29-88) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORM`A' HAS BEEN FILED <br /> LOCAL.:GEWCY COPY _ _ <br />