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'�youyc;� c STATE OF CALIFORNIA .� oti STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 6 I 3 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ©ll TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS - SPECIFY IF UNKNOWN A OWNER'S TANK I. D. #TA - 7 O ` c) 3 V B. MANUFACTURED BY: ,� Qv U ^� "3� C. DATE INSTALLED (MO/DAYNEAR) � IL D. TANK CAPACITY IN GALLONS: Coo II. TANK CONTENTS IF A-1 IS MARKED, COMPLETE ITEM C. q 1 MOTOR VEHICLE FUEL ❑ 4 OIL B -C. ❑_/1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2i 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL ❑ 2 PETROLEUM E]80 EMPTY PRODUCT ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELON) D. IF (A1) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. #: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A, B, AND C, AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF 11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM F❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1001.6 METHANOL? YES— NO— MECHANICAL UNE LEAK D. EXTERIOR ❑ 1 POLYETHYLENE WRAP ATING ❑ 3 VINYL WRAP E]4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑ 95 UNKNOWN I--]99 OTHER E. SPILL AND OVERFILL, BtC. SPILL CONTAINMENT INSTALLED (YW) OVERFILL PREVENTIO DROP TUBE YES NO STRIKER PLATE YES NO UIPMENT INSTALLED (YEAR) DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A&? 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION Ao) 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER U BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC) A © 4 FIBERGLASS PIPE C. MATERIAL AND A 1 CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 2/GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION MECHANICAL UNE LEAK 2 LINE TIGHTNESS � 3 CONTINUOUS INTERSTITIAL E] 4 ELECTRONIC UNE � 5 AUTOMATIC PUMP E 99 OTHER DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION�O/RY �❑ 33q V�ONIITORING 1:1 OZE 4 GAUGING IC TANK ❑ 5 GROUND MONITORING TESTING ❑ 6 TESTINGTANK ❑ 7 MONITORING CONTINUOUSINTERSTITIAL ❑ 8 SIR Q� (J LTJ TAw NAK GA GINGAL ❑ 10 TESTING Y TANK ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION (PERMANENT CLOSURE IN-PLACE) 1. ESTIMATED DATE LAST ED (MO/DAY� R 2 SUBSTANCE REMAINING ESTIMATED QUANTITY F I L�_GALLONS 3' WASNERT MATERIALTANK FILLED ? YES ❑ NO 2T i —1 q- 11 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 6 SIGNATURE) L0001 OGFNCV IISF ONLY THE STATE LD. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW ------ ••--••-• --- ----- COUNTY # # JURISDICTION # FACILITY # 00314P4 TANK # 03 STATE I.D.# m F 3T4101-51 I /14 lo ISRI PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS t�'�(�J FORM B (6-95) A LO