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STATE OF CwPoRraA ` STATE WATER RESOURCES CONTROL BOARD W m� a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM S >- , COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE MARK ONLY t NEW PERMIT 1:1 ONE REM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT 8 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A OWNER'S TANK 1.0.1 B. MANUFACTURED BY: Xgg X- C- DATE INSTALLED(MO/DAYMEAR) /q-7D.TANK CAPACITY IN GALLONS: O bVV ILTANKCONTENTS IFA-11SMARKED,COMPLETE ITEM C- 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1AREGULAR e 3 DIESEL ❑ 8 AVNTK)NGAS A UNLEADED 4 GASAHOL 2 PETROLEUM ❑ 80 EMPTY d I PRODUCT lb bUNLEADED PREMIUM a 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT r705 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM 0.BELOW) D. IF(A.I)G NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.ANDC,ANDALLTHATAPPLIES INBOXD A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 90 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ (Pr(mmy TWA) ❑ 9 BROKE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED 1L�—AFI 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING I/L_1 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IBLE/— G LINING MATERIAL COMPAT WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑99 UNKNOWN 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION ACO2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL DOUBLE WALL A U 3 LINED TRENCH A U 95 UNM40WN A U 00 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)6) PVC) U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIOPROTECTKN A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LIKE TIGHTNESS TESTING ❑ 3 MONRTITA C:]99 OTHER V.TANK LEAK DETECTION FE 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE I FORMATION 1.ESTIMATED DATE LAST USED(MMAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME DATE IPwR7soa .A.FM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# ZZ STATE I.D.# '�j r� c � PERMIT NUMBER I PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE e,-r FORM B (39q THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. //