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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM El COMPLETE A SEPARATE FORM FORE TANK SYSTEM. �� o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � 4/{ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �Tf � ✓E K REMO C ❑ 8 TEMPORARY TANK CLOSURE o—}ymNK REMO EO OQ� DBA OR FACILITY NAME WHERE TANK IS INSTALLED: r _ / I. TANK DESCRIPTION COMPLETE ALL ITEMS--SPECIFY IF UNKNOWN A. OWNER'S TANK 1.D. B. MANUFACTURED 8,% /! C. DATE INSTALLED(MO/DA /YEAR) - D. TANK CAPACITY IN GALLONS: II.TANK CONTENTSIFA-1 IS MARKED,COMPLETE ITEMC. �� A. [I TOR VEHICLE FUEL ❑ 4 OIL B. C. �' UNLEADED 3 DIESEL O 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑I.3TPR0DUCT ❑ 16 PREMIUMREGULAR 4 GASAHOL UNLEADED ❑ 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN O 2 WASTE O 2 LEADED ❑ 9g OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOTMARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM E:-1 8 100% METHANOL COMPATIBLEW/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR LINING F7 ❑5 GLASS LINING 6 UNLINED Imo, L-7 =+ UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE Em�NKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR)tA-r. _. IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A 401 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A®I SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 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 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A095 UNKNOWN A U 99 OTHER D. LEAK DETECTION E! r- 6T0MATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHT NESS TESTING ❑ 6 MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATERMONITOPING E�ANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATWSJ.USED(10q/ AY R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL7 YES ❑ NO�].... THIS FORM HAS BEEN 6OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DA7p (PRINTED 6 SIGNAAU S 3 .v LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNT JURISDICTION# FACILITY# TANKR!T STATE IBM vt?lo 111 PERMIT NUMBER ER PP V /DATE PERMIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERM APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. """��' `� �/-71,/c FORORUBRS