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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD iy UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM R 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 ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED 1 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 7I MO1D Tl.-c}C K PC-P12-P�, I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK 1.0.# B. MANUFACTURED BY: M008—f-1,/ W61_DIILI C. DATE INSTALLED(MODAYNEAR) A-Pgp I �CJ D. TANK CAPACITY IN GALLONS Om II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A� ,K 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C ❑ 18 REGULAR UNLEADED ❑ 3 DIESEL ❑ 6 AVIATION GAS El1b PREMIUM UNLEADED ❑ 4 GASAHOL 7 METHANOL 2 PETROLEUM F7 80 EMPTY �"1 PRODUCT E:1 1c MIDGRADE UNLEADED � 5 JET FUEL ❑ 8 M85 ❑ 3 CHEMICAL PRODUCT El 95 UNKNOWN 1--] 2 WASTE ❑ 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. 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 D AND E A TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM E 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS �4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 14C% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR F-15 GLASS LINING � 6 UNLINED 0 95 tlfIKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ Np_ D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION CORKPROTCYTON ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL,etc. SPILL CONTAINMENT STALLED(YEAR) OVERFILL EVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE 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 AG 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)AU04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U B 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 MECHANICAL ONE LEAK E 2 LINE TIGHTNESS 3 CONTINUOUS INTERSTITIAL 4 ELECTRONIC LINE M 5 AUTOMATIC PUMP DETECTOR TESTING MONITORING LEAK DETECTOR SHUTDOWN ❑ 99 OTHER V.TANK LEAK DETECTION ��❑,/��(/1 VISUAL CHECK 2 MANUAL ANNUAL RECONCIL ATION INVENORY3 MONITORING VADOZE4 GA GING IC TANK El5 MROON7 TORINGTER ❑ 6 TESTINGTANK 7 CONTINUOUS MONITORING INTERSTITIAL ❑ 8 SIR O 9 WEEKLY MANUAL ❑ 10 TMONTHLY TANK O 95 UNKNOWN ❑ 99 OTHER TANING V1.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) I.ESTIMATED DATE LAST USED(MO/DAYNR) J 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH "' SUBSTANCE REMAINING GALLONS INERT MATERIAL? Y THIS FORM HAS BEEN COMPLETED UNDER ALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED a SIGNATURE�M I�� L os- ( �L� r, rl LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY* JURISDICTION# FACILITY It TANK# p STATE I.D.# PERMIT NUMBER PERMIT APPROVED BY(DATE PERMIT EXPIRATION DATE I 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 B (6-95)