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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD .- ° ••' �' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT yy�� ❑ CHANGE OF INFOTANK CLOS ] ENK NENTLYREMOVE CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 8 TEMPORARY TANK CLOS � NN REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r /- ! I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN 'lv A OWNER'S TANK I.D.p B. MANUFACTURED 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. C. ❑ 1a REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS 2 PETROLEUM ❑ 80 EMPTY I PRODUCT ❑ 10 PREMIUM UNLEADED Q 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 10 MIDGRADE UNLEADED O 5 JET FUEL ❑ 8 M85 2 LEADED Q 99 OTHER(DESCRIBE IN ITEM D.BELOW) D. IF(A 1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.p III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑—1 DOUBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK I BARE STEEL O 2 STAINLESS STEEL ❑ 3 FIIPERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL O 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE O 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR - ❑ 1 RUBBER LINED O 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LININGVaA6 UNLINED ❑ 95 UNKN�OWWN' ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 10096 METHANOL? YES_ NO- D. EXTERIOR ❑ i POLYETHYLENE WRAP ❑ 2 COATNG ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,BLD. SPILL CONTAINMENT IN ALLE (Y R) OVERFILL PREVENTION OUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO R PLATE YES_ NO DISPENSER CONTAINMENT NO IV.PIPING INFORMATION CIRCLE A IF ABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION ' AV SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND AU BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑I MCETECRA KI UNE LEAK 2 LIME 1Ki6T LKK15 ll E rTML 4 ELEMMIC UNE 5 AUf01MTC PUTA° DCTOR ❑ TEOTINO ❑ MOMTORING ❑ LEAK CCrEC W ❑ a=M99 OTHER grid 4 V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ❑ 3 VAOZEMON ORING ❑ 4 GAUGNGAUTOMATIC TANK ❑ 5 MONITORINGROUND G ❑6 ANNUAL TESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY MANUAL ❑10 MONTHLY TANK 95 UNKNOWN ❑ 99 OTHER TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE 1N-PUCE) 1.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED OUANTTV OF 3.WAS TANK FILLED WITH YES Q NO L. 40 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 TANK OWNER'S NAME - DATE (PRINTED 6 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TAW 0 OO 7 STATE I.Dl -170 10 (- 7 3 PERMIT NUMBER PERMIT APPROVED SY/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 PLOT PL'_ FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE Y"'SRGROUND STORAGE TANK REGULATIONS FORM B 16.95) Ik w- Gla