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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL 8 <br /> UNDERGROUND STORAGE TANK PERMIT A LIC610 <br /> COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM n <br /> EMARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION —�1 <br /> NE ITEM ❑ 2 INTERIM PERMIT d AMENDED PERMIT 7 PERMANENTO/CL <br /> ❑ ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED' ly <br /> OR FACILITY NAME WHERE TANK IS INSTALLED: ( <br /> �� LVO �} <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK LD.x <br /> 8. MANUFACTURED B <br /> C. GATE INSTALLED(MOIOAY/YEAq) <br /> D. TANK CAPACITY IN GALLONS: <br /> IL TANK CO NTS IF A.I IS MARKED.COMPLETE ITEM C. <br /> AMOTOR VEHICLE FUEL ❑ d OIL :jjTR <br /> AR <br /> ❑ 2 PETROLEUM C. <br /> DED DIESEL I❑ 6 AVIATION GAS <br /> 80 EMPTY UM d GASAHOL <br /> 7 CHEMICAL PRODUCT ❑ 95 UNKNOWN DED ❑ 5 JET FUEL ❑ 7MMOL <br /> D ❑ <br /> [=0. lF(A=.11)ISN0TMAFIKED, ENTER NAME OFSUBSTANCE STORED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> C.0.S.a: <br /> III• TANK CONSTRUCTION MARKONE ITEM ONLY IN BOXES k 8.ANDC,ANDALLTHAT APPLIES INBOXO <br /> A. TYPE OF ❑ I UBLE WALL ❑ 0 SINGLE WALL WITH EXTERIOR LINER <br /> SYSTEM 2 LE WALL ❑ ❑ 95 UNKNOWN <br /> d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ S FIBERGLASS <br /> ❑ d STEEL CIAO W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br /> (Primary Tank) ❑ 9 BRONZE ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> ❑ <br /> 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ I RUBBER LINED ❑ 2 ALKYD LINING <br /> C.INTERIOR �❑ S/EPDXY LINING ❑ d PHENOLIC LINING <br /> LINING ❑ 5 GLASS LINING ❑ 6 UNLINED ilk. UNKNOWN <br /> IS UNING MATERIAL COMPATIBLE WITH 100% ME u -_ ❑ OTHER <br /> METHANOL T YES_ NO_ <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING <br /> PROTECTION ❑ 5 CATHOOIC PROTECTION ❑ 91 NONE ❑ S UN:M:WRP 9 OTHER❑ FTHERASg REINFORCED PLASTIC <br /> ❑ 99 OTHER <br /> IV.PIPING INFORMATI CIRCLE A IFASOVEGROUNOOR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE t SUCTION A U 2 PRESSURE <br /> A U 0 GRAVITY A U 99 OTHER <br /> B. C0 STRUCTK)N A 1 SINGLE WALL A U z DOUBLE WALL <br /> A U 7 LINED TRENCH A U 95 UNKNOWN <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 99 OTHER <br /> A U 7 POLYVINYL CHLORIDE PV <br /> CORROSION A U S ALUMINUM A U 8 CONCRETE (PVC) U d FIBERGLASS PIPE <br /> PROTECTION A U 9 GALVANIZED STEEL A U 7 ST TINGW/COAA U 8 100% METHANOL COMPATIBLE W/FRP <br /> A U 10 CATHOOICPFIOTECTION U 5 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAKDETECTOR ❑ 2 LINE TIGHTNESS TESTING c:]-3--A7m-snyM4 —� <br /> V.TANK LEAK DETECTION MONRORING ❑ 99 OTHER <br /> -------------- <br /> =ETANK ECK ❑ 2 INVENTORY gECONCAIATION ❑ 0 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING 5 ONI ING <br /> TING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNW40WN <br /> VI.TANK CLOSURE INFORMATION D D <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED OUANTRV OF <br /> SUBSTANCE REMAINING GALLONS S.WAS EANK RT MATE O w TH YES ❑ NO❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME <br /> (EPoNTEO A S*MNN <br /> DATE <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY x JURISDICTION x FACILITY x <br /> STATE I.D.# ® O O rANtx <br /> PERMIT NUMBER ,T ^ / PERMIT APPROVED BYIDATE <br /> .v` PERMIT EXPIRATION DATE <br /> FORK B 14901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOROIWBRI <br />