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STATE OF CALIFORNIA •`'="•• STATE WATER RESOURCES CONTROL BOj / UNDERGROUND STORAGE TANK PERMIT APP ��,�i�}}j,�M B C/ COMPLETE A SEPARATE FORM FOR EAPeANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE L DBA OR FACILITY NAME WHERE TANK IS INSTALLED: / ( _ C I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.I S. MANUFACTURED BY: C. DATE INSTALLED(MO(OAYNEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED.COMP ITEM C. ❑ 1 MOTOR VEHICLE FUEL A OIL S. C. ❑ IAUNLEADED 0 DIESEL ❑ A. d GASAHOL 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 T ❑ lb PRE IUM 5 JETFUEL ❑ 7 METHANOL ❑ S CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED OTHER (DESCRIBE IN ITEM 0. BELOW) 0. IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED mI L C.A.S.4: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.AND ALL THATAPPLIES IN BOX A. TYPE OF ❑ BLE WALL ❑ 5 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANIQ ❑ 99 OTHER S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 0 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ED7 INUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PdmwyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL L—L 55 UNIOJOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING , EPDXY LINING ❑ d PHENOLIC LINING C.INTERIOR ❑ 5 CLASS LINING ❑ 6 UNLINED UNKNOWN ❑ LININGW OOTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES—�yN/O— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 7 V WRAP ❑ s FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION Q 91 NONE —L IS/UNIONOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IFUNOERGROUND OTH6 APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A S GF- A U 1m OTHER B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A CU 76 UNKNOWN A U 98 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 ST L W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOIOPROTECTION D UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ Z NNT WKRORWG ❑ g9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ S VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIALMONITORING ❑ 91 NONEUNKNOWN ❑ N OTHER VI.TANK CLOSURE INFORMATION I.ESTIMATED DATE LAST USED(MO1DAYNR) 2 ESTIMATEOGUANTDYOF 1 WAS TANK FILLED WITH SUBSTANCE REMAINING q GALLONS INERTMATERIAL? ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLIcmrs NAME DATE IP 90&9KWATIR� LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW STATE I.D.# COUNTY t JURISDICTION t FACILITY x TANK x PERMIT NUMBER PERMIT APPROVED BY/OATE PERMIT EXPIRATION DATE FORM 8 (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A.UNLESS A CURRENT FORM A HAS BEEN FILED. _ fORO¢SIIR{