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yUun STATE OF CALIFORNIA � . i STATE WATER RESOURCES CONTROL BOARD ;<y / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Biz, "�� y: COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: d 6-.. N Dc k eynJ I. TANK DESCRIPTION COMPLETEALLRE S- SPECIFYIFUNKNOWN A OWNERS TANK LD.0 S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) D. TANK CAPACITY IN GALLONS: O 11.TANK 9ONTENTS IFA•IISMARKED,OOMPLETEITEM C. A 1 MOTOR VEHICLE FUEL a OIL 9, C. ❑ 1a REGULUNLEADED 3 DIESEL ❑ 8 AVIATION GAS 2 PETROLEUM ❑ SO EMPTY � PRODUCT ❑ 1bUNLEADED nI� 5 JETFUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE O 2 LEADED u 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A S.S: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM i 2 SINGLE WALL ❑ a SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK CD 1 RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLEW/FRP (PrimuyTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING C.INTERIOR 5 GLASS LINING 8 UNLINED LINING ❑ ❑ ❑ 96 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP a 2 COATING ❑ 3 VINYL WRAP ❑ 6 FIBERGLASS REINFORCED PLASTIC PROTECTION O 5 CATHODIC PROTECTION ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE 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 U 95 UNKNOWN A U 29 OTHER C. MATERIAL AND A U 1 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31NT KL ❑ 99 OTHER MONITORING V.TANK LEAK DETECTION + t C ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION E] 3 VAPOR MONITORING❑ < AUTOMATIC TANK GAUGING E] 5 GROUND WATER MONITORING �I J ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LA T USED(MO/DAY/YR) 2.ESTIMATED OUANTITV OF 3.WAS TANK FILLED WITH 2 J 9.Z SUBST AN CR 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 (maaTeo a swRanllSt LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY## TANK# fjNeLZ ETT STATE LDA � PERMIT NUMBER PERMIT APPROVED BY/DATE 3 FORM B (&90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR007t&9t