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wT f STATE OFCALIFORMA 09 STATE WATER RESOURCES CONTROL BOARD iy ; UNDERGROUND STORAGE TANK PERMIT APPLICATION " FORM "W� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. 9 /�� °""°""•". MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7/PERMANENTLY CLOONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY TANK CLOSURE �/g TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ALAAIiI I. TANK DESCRIPTION COMPLETE ALL ITEMS-SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.s -77 S. MANUFACTURED BY: 1 C. DATE INSTALLED(MO(7AVrYEAR) `G,N D. TANK CAPACITY M GALLONS: ILTANKCONTENTS IFA-11SMARKED.COMPL ]TEND. A Q 1 MOTOR VEHICLE FUEL 4 OIL B. C- ❑ laREGULAR 3 DIESEL 8 AVIATION GAS ❑ 2 PETROLEUM ❑ B9 EMPTYPRODUCT 1b PREMIUM 4 GASAHOL 7 METHANOL ❑ 3 CHEMICAL PRODUCT q UNKNOWN ❑ 2 WASTE O 2 UNLEADED 5 JETHER T� -- ❑ ® 99 OTHER (DESCRIBE LIN FUEL D.BELOW) D. IF(At)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 APPLES IN BOX D AND E A. TYPE OF ❑ 1 BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER 8. TANK Cell—RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS F] 4 STEEL CLAD Wl FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 0 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LWNG 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR 5 GLASS LINING ❑ 8 UNLINED E �S-uNKNowN ❑ 99 OTHER LINING 'YYEf1 IS UNWG MATERIAL COMPATIBLE WITH 1011%METHANOL? S_yNNyO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE 11iVL4_s/UN101pWN 99 OTHER E SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) t. OVERFILL PREVENTION ECUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATI N CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LNED 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 a 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORINC ❑g9 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 NTERSTITULMONITORING 02rgi NONE ❑ 95 UNKNOWN F 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMA T (MO/DAYIYR) 2.ESTIMATED OUANTDY OF 3.WAS TANK FILLED WITH SUBSTANCEREMAINNG GALLONS INERT MATERULL? YES ❑ NO❑ THIS FORM HAS BEEN COMPLETED ND P LTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE, IS TUE AND CORRECT APPLICANTS NAME pA IPBIRTEO a 91GXATURO / • � �I n� LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION i FACILITY 9 TANK 9 Od/ STATE I.D.# m o PERMITNUMBER PERMIT APPROVED 131 PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILE IO Y FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM B (12-91) ' � FORODr9R6