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STATE OF CALIFORNIA (-ou� STATE WATER RESOURCES CONTROL BOARDB� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED To DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a 3L— B. MANUFACTURED BY: C. DATE INSTALLED(M EAR) TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-i IS MARKED.COMPLETE ITEM C. A. ❑ 1 MAPRO ❑ 4 OIL S. C. ❑ 1aUNLEADED DIESEL ❑ 6 AVIATKONGAS ❑ 2 P ❑ BO EMPTY ❑ 1 PRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL O UNLEADED 5 JETFUEL ❑ O 3 CO 95 UNKNOWN O 2 WASTE O 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NAME OF SUBSTANCE STORED C.A.S.# III. TANK CONSTRUCTION ARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN BOX ONDE A. TYPE OF ❑ 1 DOUBLE WA ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDT K) ❑ 98 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIRE LASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE ❑ 7 MINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE 10 GALVANIZED STEEL ❑ UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ ALKYD LINING 3 EPDXY LINING ❑ 4 PHENOLIC LINING C 1 LIN NTERIONGR ❑ 5 GLASS LINING ❑ 6 NLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH i METHANOLS YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATI ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE O95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(VEA OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IFABOVEGRO DOR U [FUND GROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A4STAINLESS A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL DOUBLELL U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEELAA STEEL A 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A A U 7 STEELW/COATING A U 8 100% METHANOL COMPATSLEW/FRP PROTECTION A U 9 GALVANIZED EL A ROTECTION U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATI INELEAKDETECTOR 2 UNETIGHTNESSTE ING ❑ 3 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2VENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 UTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE 14ORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 8 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# m PE RMIT 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 N FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG ♦TIONS FORMS (12-91) 3�y I p FORNW&R6