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STATE OF CALIFORNIA p9 STATE WATER RESOURCES CONTROL BOARD c,o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM COMPLETE A SEPARATE FORM -�FOR �.EACH TANK SYSTEM. MARK ONLY F-11 NEW PERMIT [—] 3 RENEWAL PERMIT5 CHANGE OF TION ❑ 7 PERMANENTLY CLOSED ON ITE ONE ITEM 712 INTERIM PERMIT F7 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED I DBA OR FACILITY NAME WHERE TANK IS INSTALLED: :�^ I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.Y B. MANUFACTURED BY: C. DATE INSTALLED(MOMAYNEAR) 0. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A l MOTOR VEHICLE FUEL ❑ 0 OIL B. C. ti REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY i PRODUCT 1D PREMe1M UNLEAD® s GASAHOL ❑ 7 METHANOL to M]GRADE UNLEADED5 JET NEL ❑ B MBS ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED H 99 OTHER IDESCRIBE N ITEM D.BELOW) 0. IF(Al)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.N III. TANK CONSTRUCTION K ONE ITEM ONLY IN BOXES A B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1DOUBLE WALL F73 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNONM SYSTEM C—] 2 SINGLE WALL ❑ d SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 0 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 ❑ 1 RUBBER LINED 2 ALKYO LINING F-13 EPDXY LINING ❑ 6 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED Fl95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WI 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 AnNG ❑ 3 VINYL WRAP ❑ 6 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 E ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,st0. SPILL CONTAINMENT INSTALLED(YEA OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO_ STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSU A U 3 GRAVITY A U d FLEXIBLE PIPING A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U Z DOUBLE W A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS S A U 3 POLYVINYL CHLORIDE(PVC)A U s FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPR ON A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 Iaunacl Lae[IFAK 2 IAIE 1NNlrriss 3 caxlanpus ❑A BFOI9YeG LIM s AumuAnc PUIr ❑ yy OTHER BETEcrOR ra<slw0 aoNraRNa vAK oE1[crOR PNrooar V.TANK LEAK DETECTION ❑ i VISUAL CHECK ❑ 2 RECONCIUNUAL ATT10NO� ❑ 3 MONITORING ZE < GAUGING AUTOMATIC TANK ❑5 MON MONITORING OUNDWATER ❑8 TESTING ANNUAL TANK ❑ 7 MONITORING INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL 10 MONTHLY TANK 95 UNKNOWN ❑99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.Esn!Z DATE LAST USED( Y ) 2.ESTIMATED QUANTITY OF I 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAININGONS INERT MATERIAL 7 7l-IIS FORM HAS BEEN C MPL ED UNDER PENALTY OF PERJURY,AND TO THE BE OF MY KNOWLEDGE IS TRUE AND CORRECT TANK OWNER'S NAME DATE (P'.RM 510NATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY k JURISDICTION a FACILITY k TANK a STATE I.D.4 m 9 Z l/ PERMIT NUMBER PERMIT APPROVED BYIDATE 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{ FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TH' ODLTI N FORMS ( A5) OFNKRC-1J ST RAN