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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Bim ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT - 1 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY 0. "O CN SITE 'a ONE REM 2 INTERIM PERMIT 1 a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REUCV DBA OR FACILITY NAME WHERE TANK IS INS-,91 E0: 'El.e, I. TANK DESCRIPTION COMPLETE 4--VS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D. S. MANUFACTURED BY: moogtvv (Ay C. DATE INSTALLED(MOIDAY,YEAR) g �, D. TANK CAPACITY IN GALLONS:Z5, , b H ILTANKCONTENTS IFA.IISVARM1E_.,�+_.E,ITEMc. 'j 1 MOTOR VEHICLE FUEL ❑ LREGULAR 3 DIESEL 1 ? AC.A'a7N GAS A. T-zt ^.l B. C. UNLEADED a GASAHOL —2 PETROLEUM VFTY 1 PRODUCT ❑ tb PREMIUM ❑ VCT�ANOL UNLEADED ❑ 5 JET FUEL❑ 3 CHEMICALPRODUCT t1NKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ W OTHER (DESGFISE 'S -u J. BELOW) D. IFIA.I)ISNOTVA;lED, ENTER NAVE STORED C.A.S.a: III. TANK CONSTRUCTION MAR(OSE-V-N,v IN BOXESA,B.AN'DC.ANDALLTHAT APPLIES INBOX D AND A. TYPE OF I DOUELE WALL Ji 3 SINGLE WALL WITH En EROR LINER O 95 UNKNOWN 1 SYSTEM ❑ 2 SNGE Y;ALL _I a SECONDARY CONTAINMENT (VAULTED TRRlQ ❑ 99 OTHER I 6ARE STEEL 2 STAINLESS STEEL ❑ 3 FIBERGLASS A STEEL CLAD W/FIBERGLASS RE'N,=-EC PLASTIC B. TANK = MATERIAL ❑� 5 CONCRETE '� 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM O B iD]x METHANOL COMPATIBLE W'=R` (Pri,aryTank) I— 9 ERCCZE 10 GALVAN12E0 S-EL ❑ 95 UNKNOWN ❑ 99 OTHER II I F'-:BER LWED 2 A'_KYD LINING ❑ 3 EPDXY LINING ❑ a PHENOLIC LINING C.INTERIOR I� 5 GLASS LIN'NG �1�16 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS L'.N:NG VR ER'AL CCV=A'E_E Y-H 10 METHANOL? YES_ NO— D.CORROSION 'TETE= T PO'°`THYLENc '%Z — _-z 7 2 COATING ❑ 3 VINYL WRAP a FIBERGLASS REINFORCED P,AS-C PROTECTION r_ 5 CA'-0DC PRO'EC CN 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SP LCON?A'\VE S" SSALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEA IV.PIPING INFORMATION CIRC'EA =GCJEGROUNDORU IFL'NDERGROUND,BOTH IFAPPLICABLE A. SYSTEM TYPE A t sUGION A U 2 PRESSURE A U 3 GRAVITY A U N OTHER B. CONSTRUCTION A U 1 SINGLE VIA-L A 12 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U P9 C a C. MATERIAL AND A U 1 SAFE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W COATING A V 6 IO METHANOL`CDM-A GLE V.'IFRP PROTECTION A U 9 GALVANI2<JS-c A U 10 CATHODICPROiECT10N A U 95 UNKNOWN A6,;69 OTHERy[WI �rLti D. LEAK DETECTION AUTOMATIC L:NE L EAK DETEC70R ❑ 2 LINE TGHTNESS TESTING ❑ 40HRORMG 9D OTHERTI ,- V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOIE MONITORING X A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING�Z 7 INTERSTITIAL MCNRORIN'G ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYnRI l 12.ESTIMATEDOUANTITY OF 13.WAS TANK FILLED WIT/{ ) S rl NO ❑ KA $UoSTANCE R EMAIN'ING GALLONS INERTMATERIAL? N U THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND T#FHE BEST4F MY KNOWLEDGE, IS TRUE AMD CORRECT APPLICANTS NAME A N, DATE / IRRI a5 4aTV El j /!�Y , I L� ACJ/✓ T LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION s FACILITY N - TANK 9 STATE I.D.# m 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. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORDS 6Ra FORMS (12 91)