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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ar UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM eatj �5� HA COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ED ON ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE ' DBA OR FACILTTY NAME WHERE TANK IS INSTALLED: ' I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# 8. MANUFACTURE BY: � C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IFA-1 IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. ISZla REGULAR UNLEADED � 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY �i PRODUCT 07 10 PREMIUM UNLEADED 4 GASAHOL 7 METHANOL 1c MOCiRADE UNLEADED 5 JETFUE B M85 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE N UEM O.SELOM D. IF(A1)IS NOT D, ENTER NAME OF SUBSTANCE STORE C.A 10: III. TANK CONSTR TION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN BOX D AND E A TYPE OF ❑ 1UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR UNER ❑ 5 INTERNAL BLADDER SYSTEM E] 95 UNKNOWN SYSTEM ❑ 2 SI WALL ❑ 4 SINGLE WALL IN A VAULT ❑ N OTHER B. TANK ❑ I SAFEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCR ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY UNING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATI8 WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCE PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ❑ I NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLS EAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO N STRIKER PLATE YES_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GRO LINOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRES E A U 3 GRAVITY A U 4 FLEXISLEPIPING A U 99 OTHER S. CONSTRUCTION A U I SINGLE WALL A U T DOUBLE LL A U 3 UNE TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS EL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U I CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZE STEEL A U 10 CATHODIC PR ON A U 95 UNKNOWN A U S9 OTHER D. LEAK DETECTION Q1 oETOEaRrraAK [:]2TIGnESI C-]3= ❑ ❑ 99 OTHERTEN IEuc oETE01oR slMroamH V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECOUAL NCILIATIONORV ❑ 3 MONITORING 4 GING C TANK ❑5 GROUND WATER MONRORING ❑e ANNUALTESTING ❑ 7 CONTINUOUS INTERSTITIAL ❑ 8 SIR ❑ S WE�TANKGAUGINUAL 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.E5TIMATE LAST USED(MO/DAY/YR) ZESTIMATEDQUANTITYOF I S TANK FILLED WITH VES [:] NO ❑ -� SUBSTANCE REMAINING GALLONS I WAS RINERT MATERIAL THIS ORM HAS BEEN CbMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME GATE (PRNITDMSIGNAIVRET LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW T COUNTY# JURISDICTION# FACILITY# TANK# STATE LD:# m61162 ' 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 PIAT '. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TGROUND STORAGE TANK REGULATIONS FORM 0 (695) ... g v �� X-&-e