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STATEOFCAUFORNIA °+ STATE WATER RESOURCES CONTROL BOARD a> - , ° d� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 6 to . ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED S ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 9 TEMPORARY TANK CLOSURE TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1T G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.0.a B. MANUFACTURED Sr. C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: 0 II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. ❑ 1 MOTOR VEHICLE FUEL d OIL B. C. 1a REGULAR UNLEADED 3 DIESEL ❑ 6 AVIATION GAS A /a PREMUM UNLEADED g 4 GASAHOL ❑ T METHANOL ❑ 2 PETROLEUM ❑ 00 EMPTY ❑ I PRODUCT Ic MIDGRADE UNLEADEDnT� 5 JETFUEL 1:1B MBS 1--] 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN L.IO T WASTE ❑ 2 LEADED IJ 99 OTHER(DESCRIBE N ITEM D.BELOW) D. IF(Al)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED D ` C.A.S.a ILL TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF SINGLE DOUG WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM 1:195 UNKNOWN SYSTEM G2 22 SINGLE WALL ❑ d SINGLE WALL W A VAULT ❑ OTHER B. TANK 1=1 ' BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ T ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 AL.KYO LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ a UNLINED 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 0 FIBERGLASS REINFORCED PLASTIC CORROSION91 NONE ❑ UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION SPILL CONTNNMENTINSTALLEO(Y ) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) E SPILL AND OVERFILL,ate DROP TUBE YES_ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES AJn NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPUCABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 UNED TENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND p 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U T STEEL W/COATING A U S IOD% METHANOL. COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 M:CXNaTAI UIE UAA 2 1a1E iK11IN35 3=mvo 01R virInA IAL ❑4 L1EGmML UxE Q 5 AVTgMRC Plus r+�CTH01 D. LEAK DETECTION ❑ � ❑ *Es19E ❑ MGNroRNG vAa tETEGT011 9A1100.N1 LAS V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 MANUAL RECONCILIATION ❑ 3 MONIITORING OZE ❑ 6 AUTOMATIC GA�MAG C TANK ❑5 MOGROUND TORING ❑5 ANNITESTINGTANK ❑ T MONITOR U INTERSTITIAL ❑ B SIR ❑ 9 WEEKLY GAUGINGMANUAL ❑ 10 MONTHLY TANK ❑ 95 UNKNOWN Q B9 OTHER VI.TANK CLOSURE INFORMATION(PERMAN T CLOSURE IN-PLACE) �///��' 1.ESTIMATT U Y y 2'��ANDE UANT1N NGF GALLONS 3.WASINERT MATERIATANK FILLED ALL? C:]E DATE 13( YES NO THIS FORM HAS BEEN COMPL ED NOER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME DA (PPIMm A 31G.ATUPEI -120F 1/ l LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY a JURISDICTION a FACILITY k' TANK a STATE LDJ m r PERMIT NUMBED PERMIT APPROVED SYIDATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT AF TION-FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED N C MUST BE COMPLETED FOR INSTALLATIONS.THISFORM SHOULD BE ACCOMPANIED BY A PLO\r„� FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T . 'RGROUND STORAGE TANK REGUULATIRNS� n FORMS (695) I ,- -(/� XV