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• STATE OF CAUFDRNA • STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM _ e YII,w-CT.a 0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, MA;ITEM LY ❑ 1 NEW PER ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O e ON ❑ 2 INTERIM PERMIT T PERMANENTLY CLOSED ONSITE ❑ 4 AMENDED PERMIT ❑ 8 TEMPORAgY TANK CLOSURE O 8 7ANK REMOVED DBAACILITY NAME WHERE TANK IS INSTALLED: E A•� F Q �iN E V I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN J 5tS57/ A. OWNER'S TANK 1.D.r B. MANUFACTURED BY: C. GATE INSTALLED(MO/OAYKEAR) L C. TANK CAPACITY IN GALLONS: 3 ILTANKC EMS IFA-11SMARKED.COMPLETEITEMC. A. 1 MOTOR VEHICLE FUEL ❑ 6 OIL B. / C. ❑ 1dUNLEADED 8 3 DIESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM 80 EMPTY 1 PRODUCT ❑ IDPREMIUM 4 GASAHOL ,_,_ FADED ❑ 5 JETFUEL ❑ T METHANOL ❑ 3 CHEMICALPROOUCT ❑ 95 UNIOJOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.r: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A S.AND C.AND ALL THAT APPLIES IN SOX [B.::TA:NK TYPE OF ❑ /--UBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM E�r2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CLAD Wr FIBERGLASS REINFORCED PLASTIC IAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 INUM 8 100% METHANOL COMPATIBLEW/FRP ank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL 5 UNKNOWN ❑ 99 OTHER .INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYO LWING ❑ 3 XY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 6 UNLINED 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E V L WRAP ❑ d FIBERGLASS REINFORCED PLASTIC PROTECTION 5 CATHODIC PROTECTION E:] 91 NONE 5 UNIOJOWN ❑ 99 OTHER IV.PIPING INFORMATI CIRCLE A IFABOVEGROUNOOR U IF UNDERGROUND.BOTH IFAPPLICABLE A. SYSTEM TYPE A LU SUCTION A U 2 PRESSURE AU 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH U 5 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 d FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 8 CONCRETE A U 7 STF,�L�W/COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A 5 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAKOETECTOR 2 LINE TIGHTNESS TESTING31NT RSTI IAL ❑ MONITORING ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ d OMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ 91 NONE ler95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MOIDAYNR) I 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ NO ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT- APPLICANTS NAME IPRINTEOaSIGNA%RE) DATE 9 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW STATE I.D.# COUNTY N JURISDICTION 9 FACILITY x TANK#ITq PERMIT NUMBER Ill/ L.L..LJ d O 0 C7 d PERMIT APPROVED BYIDATE I PERMIT EXPIRATION DATE FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORo=B.R4