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• � "�g6V"C.s C STATE OF CALIFORNIA : ,fy STATE WATER RESOURCES CONTROL BOARD a m UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM R ate . COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVE Jr DBA OR FACILITY NAME WHERE TANK IS INSTALLED; I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK 1.D.# t ri w Sr 7 B. MANUFACTURED BY: �� Q /1/vleJ6 C. DATE INSTALLED(MOIDAYNEAR) !?e9 Q. TANK CAPACITY IN GALLONS: �Q�O e!> II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. 2r"1-MOTOR VEHICLE FUEL Q 4 OIL B. C 1a REGULAR UNLEADED 0 3 DIESEL L] 6 AVIATION GAS 2 PETROLEUM 80 EMPTY L O I�J I 1 PRODUCT lb PREMIUM UNLEADED 4 GASAHOL a 7 METHANOL lc MIDGRADE UNLEADED 5 JET FUEL 0 8 M85 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE 2 LEADED 0 99 OTHER(DESCRIBE IN ITEM D.BELOW) 0. IF(A.1)IS MOT 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 D AND E A. TYPE OF Ep-1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER 5 INTERNAL BLADDER SYSTEM [--] 95 UNKNOWN SYSTEM [-] 2 SINGLE WALL O 4 SINGLE WALL IN A VAULT 99 OTHER B. TANK Q 1 BARE STEEL F7 2 STAINLESS STEEL FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE 6 POLYVINYL CHLORIDE 7 ALUMINUM 8 100% METHANOL COMPATIBLE WIFRP (Primary Tank) 9 BRONZE l� 10 GALVANIZED STEEL 95 UNKNOWN O 99 OTHER C.INTERIOR u 1 RUBBER LINED 2 ALKYD UNNG 3 EPDXY LINING 4 PHENOLIC LINING LINING OR 5 GLASS LINING 6 UNLINED 95 UNKNOWN F-1 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR F7 1 POLYETHYLENE WRAP F-] 2 COATING 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION E] 5 CATHODIC PROTECTION E] 91 NONE ❑ 95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL,II SPILL CONTAINMENT IN�LED(YEAR) OVERFILL PRON EQUIPMENT INSTALLED(YEAR) DROP TUBE YES Pf NO STRIKER PLATE YES Ae NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVEGROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION Ao 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION AO 1 SINGLE WALL A U 2 DOUBLE WALL AQ 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)Ao 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELW/COATING A U a 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER MECHANICAL ONE LEAK 2 LINE TIGHTNESS WNTINLOUS INTERSTITIAL 4 ELECTRONIC LINE AUTOMATIC PUMP D. LEAK DETECTION OETECT 11 a TESTING MONITORING LEAK DETECTOR SHUTDOWN [71 99 GTNER V.TANK LEAK DETECTION GROUND WAUAL 1 VISUAL CHECK 2 RECONCILMANUAL IIATIONORY E] 3 MONITORING VADOZE 4 AUTOMATGAUGINGIC TANK 5 MMONITORING7ER 6 TESTINGTANK �7 CONTINUOUS MONITORING INTERSTITIAL O 8 SIR 9 WEEKLY MANUAL ❑ 10 MONTHLY TANK 95 UNKNOWN 99 OTHER TANK GAUGINGTESTING VI,TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLA ) 41,9"- LAST /p"LAST USED(MOICAYIYR) 2.ESTIMATED OIJAhTITY F 3.WAS TANK FILLED WITH SUBSTANCE RE AININ GALLONS INERT MATERIAL? YES ] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P JU Y ND T E BEST OF MY KNOWLEDGE, IS TRUE AIVO CORRECT TANK OWNER'S NAME IA (PRINTED S SIGNATURE) �rsj+� n /J A� � Y Vr "---� DATE ZZ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSE41F THE FOUR NUMBERS BELOW STATE I.D:# COUNTY# JURISDICTIONkI FACILITY# TANK# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLIC -FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. F MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PULE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE�GROUND STORAGE TANK REGULATIONS FORM B (6.95)