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:� e STATE OF CALIFORNIA ' STATE WATER RESOURCES CONTROL BOARD w"'ft8 n P UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM o.„,.. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 7 PERMANENTLY CL SED ON SITE may( ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ B TANK REMOVED ❑ MARK ONLY 1 NEW PERMIT ❑ 8 TEMPORARY TANK CLOSURE 2 INTERIM PERMIT 4 AMENDED PERMIT OG ONE ITEM 1 G DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN B. MANUFACTURED BY: 1 A. OWNERS TANK I.D.# D. TANK CAPACITY IN GALLONS: SOS C. DATE INSTALLED(MO/DAYNEAR) L,wk+�r) ILTANKCONTENTS IFA.11SMARKED,COMPLETEITEMC. ❑ 1a REGULAR O 3 DIESEL ❑ 6 AVIATIONGAS 4 OIL B. C UNLEADED ❑ 4 GASAHOL ❑ 7 METHANOL A ❑ 1 MOTOR VEHICLE FUEL 1 PRODUCT 1b PREMIUM 2 PETROLEUM ❑ ❑a0 EMPTY ❑ UNLEADED ❑ 5 JET FUEL ❑❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D.BELOW)3 CHEMICAL PRODUCT ❑ C.AS.#: D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES A,B.ANDC.ANDALLTHAT APPLES INBOX D AND ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANIQ E] 99 OTHER SYSTEM �y 2 SINGLE WALL Imo, 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ E]3 FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK D ❑ a POLYVINYL CHLORIDE ❑ 7 ALUMINUM E] B 100% METHANOL COMPATIBLE WIFRP MATERIAL ❑ 5 CONCRETE (PHmaryTank) ❑ 9 BRONZE ❑ t0 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING 6 GLASS LINING 95 UNKNOWN 9B OTHER C.INTERIOR ❑ ❑ e UNLINED ❑ LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION PROTECTION ❑ 5 CATHCOICPROTECTK)N ❑ 91 NONE ❑95 UNKNOWN 99 OTHER ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTX)NEDUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNDERGROUND,BOTH IFAPPLICA3LE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A Y 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL OOMPATBTLEWSRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 96 UNKNOWN A U 99 OTHEfl D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE STING ❑ LIONRORING ❑99 OTHER V.TANK LEAK DETECTION FE-1 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED ATE LAST USED(MO/DAY/YR 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH �j n T11�» SUBSTANCE REMAINING GALLONS INERTMATERIAL7 YES ❑ �.Ll-I THIS FORM HAS BEEN CO PL TED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTEO A SIGNATUPE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FQVRNUMBERS-BELOW COUNTY# JURISDICTION M. - FACILITY Q TANK#GO 1 STATE I.D.# m Fyi D I (..I 0 PERMITNUMBER & PERMITAPPROVEDBY/DATE MIT EXPIRATION DATE ?.„tjF506o9ff 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 1 FORM B (12-91) FORpnU