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7- 0 4• 1999 n v ,STATE OF CALIFORNIA • ��~� • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATIC4 ' COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED All DBA OR FACILITY NAME WHERE TANK IS INSTALLE I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.# B. MANUFACTURED BY: C. DATE INSTALLED(MC/DAY/YEAR) D. TANK CAPACITY IN GALLONS: II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. ❑ to REGULM UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS PETROLEUM ❑ 80 EMPTY a PRODUCT ❑ 1b PREMIUM UNLEADED ❑ 4 GASAHOL ❑ ] METHANOL ❑ 1c MIDGRADE UNLEADED ❑ 5 JET FUELB M85 3 CHEMICALPRODUCT ❑ 95 UNKNOWNWASTE 2 LEADED 99 OTHER(DESCRIBE IN ITEM D.BELOM D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED .A S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C,AND ALL THAT APPLIES IN BOX D AND E ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM [:] 95 UNKNOWN A. TYPE OF 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 W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PHmary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING A'UNLINED ❑ 95 UNKNQWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 1W% METHANOL? YES_ NO D.EXTERIOR ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION1 NONE 95 UNKNOWN 99 OTHER PROTECTION ❑ 5 cATHoDIc PROTECTION ❑ ❑ SPILL CONTAINMENT INSTALLED ) OVERFILL PREVENT] OUIPMENT INSTALLED(YEAR) E.SPILL AND OVERFILL,etc. DROP TUBE YES_ NO IKER PLATE YES_ NO DISPENSER CONTAINMENT Y NO IV.PIPING INFORMATI CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A INGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND 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 6 CONCRETE A U 7 STEEL W/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 LINE D. LEAK DETECTION ❑1 NECRMIIGL U& 2 LNTK.HT W ❑3 LCNIINUWS IMERST [D4 ELECIRGNIC UNE ❑5 AUfONARc PUMP ❑ 99 OTHE aE1 on ❑ TEsm+G E uaurauxG v of =R 9NI100WN V.TANK LEAK DETECTION ToMAT❑ 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY ❑ 3 ATION MONITORING ❑ 4 Au GAUGWGIC TANK ❑ 5 MONITORINGGROUND TER ❑ 6 TESTINGTANK ❑ 7 MONTORNG INTERSTITIAL ❑ 8 SIR ❑ 9 WEEKLY MANUAL ❑10 MOTEsNTHLY TANK g5 UNKNOWN ❑99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) MATE DA LAST USED 2.ESTIMATED QUANTITY OF _L ) 3.WAS TANK FILLED WITH YES ❑ O SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN4WPLElFDUN R PEN TY ER Y,A Nr T TANK OWNER'S E DAILE (PRINTED 4 SIGNATURE) LOCAL AGENCY USE ONLY THE STATE LD.NUMBE COMPOSED OF THE FOUR NUMBERS BELOW �° \ COUNTY# JURISDICTION# FACILITY If /a(j0 I TANK# STATE I.D.# m = 15001 b 0 J PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE /D o THIS FORM MUSTSHOULD BE ACCOMPANIED BY AI PLOT APPLICATION RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STTORAGE TANK REGULATIONS THIS FORM UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR IONS / FORMS (6-95) 0 •