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STATE OF CAUFORMA STATE WATER RESOURCES CONTROL D 6-1 UNDERGROUND STORAGE TANK PERMIT A L � • Y/ p COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT CHANGE OF INFORMATION ❑ -7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED J �/ DBA OR FACILITY NAME WHERE TANK IS INSTALLED: -kV, � yy I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.At B. MANUFACTURED BY: v— C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ A OIL 8. C, ::REGULAR UNLEADED S DIESEL ❑ e AVIATION GAS A 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ 1D PREMIUM d GASOHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL 7 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.0: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A TYPE OF ❑ 1 BLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL Fl2 STAINLESS STEEL F72 FIBERGLASS ❑ A STEELCLAO W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7INUM ❑ B 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑� LINING ❑ l PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 95 UNKNOWN ❑ oo OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METANOL? YES_ NO— D.D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING F7yI 2 / AP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE UNIWOWN ❑ 99 OTHER IV.PIPING INFORMATI CIRCLE A IFA80VEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE U 1 SUCTION A U 2 PRESSURE A U 2 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UN104OWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U S POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U a CONCRETE A U 7 ST EL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A V 10 CATHOOICPROTECTION Afy 95 UNKNOWN A U 99 OTHER O. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE ING ❑ T NORRORuq ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ S VAPOR MONITORINGAUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIALMONITORING El91 NONE 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED GDANTITY OF 1 WAS TANK FILLED WITH SUB STANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRIRTE9 a SNi MRX) 1 IF LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION A FACILITY# TANK# STATE LDA COUNTY 10101U D 1101 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORMS (390/ THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. fCWA¢716M