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• STATE OFCAUFORMA • _�"�•;•,•. ��. STATE WATER RESOURCES CONTROL BOARD i m UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM 9 na COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 8 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 0 TEMPORARY TANK CLOSURE ❑ 0 }ANK REMOVED ' -Z DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS SPECIFY IF UNKNOWN A. OWNERS TANK I.D.N (/ B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: CJi Yy/JC7 ILTANKCONTENTS IFA-119 MARKED,COMPLETE ITEM C. 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ 1a REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATK)NGAS A. 4 oABAHOL ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 18PREMIUM 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ AS UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 96 bfHER (DESCRIBE IN ITEM D.BELONG D. IF(A.1)19 NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.0 i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.0.ANDC,ANDALLTHAT APPLIES IN BOXD A. TYPE OF r-1I DOUBLE WALL F-13 SINGLE WALL WITH EXTERK)R LINER 85 UNKNOWN , SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEOTANK) ❑ 00 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/PI8ERGLA99 REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 MINUM ❑ 8 100-A METHANOL COMPATIBLE WIFRP (PrimBryTank) ❑ 0 BRONZE ❑ 10 GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 9 EVOXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED 0�08 UNKNOWN ❑ 00 OTHER LINING IB LINING MATERIAL COMPATIBLE WITH 10D%METHANOL 7 VES— NO— D-. )_D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑.9.VINYL WRAP, O 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PAOTECTION ❑ 01 NONE El 05 UNKNOWN ❑ 00 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,00TH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A 708 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS $TEFL A U 2 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEE W)/COATING A U S 1001A METHANOL COMPATIBLE WIFRP PROTECTION A U 0 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AU 9111 UNKNOWN A U 1W OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR' ❑ 2 LINE TIGHTNESS TESTING ❑ MONRORNG AL ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 8 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTEASTITIALMONITORING ❑ 91 NONE ❑ 08 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED GATE LAST USED(MO/DAY/YR) 2.ESTIMATED REMAINING OF 3.WAS TANK FILLED WITH YES ❑ NO❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 4 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE 1,0.NUMBER IS COMPOSED OF THE POUR NUMBER$AEL6W COUNTY 0 JURISDICTION 0 FACILITY# AN �—�--�T--�K—0—�--�� STATE I.D.# � F l J PERMIT NUMBER PER MIT APPROVED BY/DATE I PERMIT EXPIRATION o0y-(, )/ 011 FORM B (0901 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. fin/ / FOR0034 BIS