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� e STATE OF CALIFORNIA ^`' w.•..' 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM D r . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEWPERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ONSITE ONE ITEM L 2 INTERfM PERMIT 7� 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE F7 8 TANK REMOVED I DSA OR FACILITY NAME WHERE TANK IS INSTALLED: f I MCQ Trz L)C}C PLazP� I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN .A. OWNER'S TANK I.D.N B. MANUFACTURED BY: ^took 44i lAj6mN C. DATE INSTALLED(MOMAYNEAR) �.I[- �. D. TANK CAPACITY N GALLONS. O� If.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL 4 OIL B. C 1a REGULAR UNLEADED 3 DIESEL ,� 6 AVIATION GAS 1b PREMIUM UNLEADED 4 GASAHOL 7 METHANOL 2 PETROLEUM � 80 EMPTY 1 PRODUCT �i 1c AIIpGpApE UNLEADED � 5 JET FUEL � 8 MBS G 3 CHEMICAL PRODUCT Q 9S UNKNOWN Q 2 WASTE L❑� z LEADED 99 OTHER(DESCRIBE IN ITEM 0.BELCV+ D. IF(A.1)tlS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTcRIOR LINER G 5 INTERNAL BLADDER SYSTEM C 95 UNKNOWN SYSTEM 2 SINGLE WALL 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK 1 BARE STEEL 2 STAINLESS STEEL F-1 3 FIBERGLASS 4 STEEL CLAO W!FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 1-1 7 ALUMINUM �! 8 100% METHANOL COMPATIBLEWIFRP (Primary Tanis) 9 BRONZE 1p GALVANIZED STEEL 35 UNKNOWN 99 OTHER C.INTERIOR a 1 RUBBER LINED 2 ALKYD LINING 0 3 EPDXY LINING Q 4 PHENOLIC LINING LINING OR 5 GLASS LINING �5 6 UNLINED 95 VKNOWN 99 OTHER COATINGIS LINING MATERIAL COMPATIBLE WITH 100% METHANOL. YES ✓' NO— D.EXTERIOR I PCLYETHYLENE WRAP 2 CCATING 3 VINYL'WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION 5 CArHoolc PROTECTION0 91 NONE 195 UNKNOWN [ 99 OTHER SPILL CONTAINMENT STALLED(YEAR) OVERFILL EV ENTION EQUIPMENT INSTALLED(YEAR) _ E.SPILL AND OVERFILL,etc. DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A T ABOVEGROUND OR U IF UNDERGROUND.BOTH IF APPLICABLY A. SYSTEM TYPE A U 1 SUCTION A&2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A0 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(D4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL Wl 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 1 AIEC.ICAI LANE LEAK 2 UNE TIGHTNESS 3 GmMNULIGS IHR_116T IAL 4 ELECTA�(NN771C UNE 5 AUtO�AYIC PUMP f�' 99 p ER D. LEAK DETECTION DETec R 0 'ESTING MOMTORING ❑ ,FAK DETEcrDR &ArmcwN V.TANK LEAK DETECTION 1 VISUAL CHECK ❑ 2 REGOUNCIUATIONINVENTORY ❑ 3 VADOZE MO I ORING 4 AUTOMATGAUGING MONITORING TANK 5 MONITORING UND TER `--, 6TANK TESTING 7 CONTINUOUS INTERSTITIAL 8 SIR 9 WEEKLY'MANUAL 10 MONTHLY TANK 95 UNKNOWN 99 OTHER MONITORING - VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN•PLACE) 1.ESTIMATED CATE LAST USED(MC[DAYNR) 2..ESTIMATED QUANTITY OF A 3,WAS TANK FILLED WITH AJ � SUBSTANCE REMAINING GALLONS I INERT MATERIAL 9 THIS FORM NAS BEEN COMPLETED UNDER ALTY OF PERJURY,AND TO THE BEST OF'vY KNCWL EDGE, IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED d SIGNATURE] r�C ZF n LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION N FACILITY N TANK# r STATE E.D.; m 1�j�, PERMIT NUMBER I PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE d 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 6 (6-95)