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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FOR COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 3 �I..W.. l I o S MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATON ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 1 Y C/. I. TANK DESCRIPTION COMPLETE ALL ITEMS_ SPECIFY IF UNKNOWN A OWNERS TANK I.D.R O` 5 B. MANUFACTURED BY: T C. DATE INSTALLED(MCIDAY/YEAR) J �L� D. TANK CAPACITY IN GALLONS: �•C/ II.TANK CONTENTS IF A-1 1S MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1e;REGULAR UNIEADEO 3 DIESEL ❑ 8 AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY }Szr 1 PRODUCT 10M UNLEAD® 4 GASgHOL ❑ 7 METHAN3 CHEMICAL PRODUCT ❑ 85 UNKNOWN ❑ 2 WASTE ❑ 1cDE UNLEADED Q 5 JETFUEL ❑ B M85 2D ❑ 99 OTHER(DESCRBE N ITEM D.BELOW) 0. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTAGE STORED C.A S.9: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,S,AND C.AND ALL THAT APPLIES IN BOX D AND E �y5 A. TYPE OF F-1i DOUBLE WALL [:] 3 SINGLE WALL WITH EXTERIOR LINER [:15 INTERNAL BLADDER SYSTEM I.[ 195 UNW40WN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL N A VAULT ❑ X1 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM a 8 100% METHANOL COMPATISLE WIFRP PdMBYTnb ❑ 9 BRONZE ❑ /0 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 8 UNLINED to 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODICPROTECTION ❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BSO. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENDON OUIPMENT INSTALLED(YEAR) DROPm YES_ NO STRIKER PLATE YES_ NO v DISPENSER CONTAINMENTYES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 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 B CONCRETE A U 7 STEEL WICOATIC A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 4D 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑t 1[cKANcu LNE UAK ❑2 M19 1X4NLs5 ❑3 wKIEAlOus NlvsmML ❑4 LLEcnromc L91E ❑s AI901NTK PVIP ❑ OTHER 9L am rEsrxo K5N19Mu rFNc oElEcraR 9M m V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATION CIU TOAL NY ❑ 3 MOONITORING ❑ 4 GAUGG AUTOMATIC TANK ❑ 5 GROUND MONITORING ❑8 ANNUNGTANK ❑ 7 CONTINUUO4UG INTERSTITIAL El 8 SIR ❑ 9 WEEKGA MANUAL ❑10�TNTHGY TANK 95 UNKNOWN ❑99 OTHER STIN VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) 1.ESTIMATED DATE LAST D( OIDA"R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED NTH �jpT�''11 SUBSTAGE REMAINING GALLONS INERT MATERIAL 7 YES ❑ NO�'11 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNEWS NAME0 DATE OY1NT®4 SK9lATUR �, /' ' 05� RAG (�L TE 3�O 6 LOCAL AGENCY USE ONLY THE STATE L .NUMBER IS COMPOSED OF THE FDA NUMBERS BELOW COUNTY B JURISDICTION B FACILITY B TANK 9 STATE ILD.# m = I I I I _T_Tj I PERMIT NUMBER PERMIT APPROVED BYIDATE 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 PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM 8 (845)