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♦4�o•n••�C4 STATE OF CALIFOWaA STATE WATER RESOURCES CONTROL BOARD ORM B v` y, o' UNDERGROUND STORAGE TANK PERMIT APPLICATION-F COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ T PERMANENT CLOSE SI ` ❑ 5 CHANGE-DF TNF.ORMATION ❑ B TANK REM ED EW.PERMIT ❑ 7 RENEWAL PERMIT ❑ 6 TEMPO MRV TANK CLOSURE MARK ONLY a AMENDED PERMIT y ONE ITEM 2 IN IM PERMIT / . / 3 RE TANK IS INSTALLED: DBA OR FACT IN NAME !/ I. KNDWN TANK DES ION COMPLETE 011 ITEMS- SP FY IF LINB MANUFACTURED BY: UD A. OWNER'S TANK I.D.+ / D. TAN —/ C. DATE INSTALLED WOIDAYIYEARI ` 5 AVIATION GAS IRREGULAR 8 3 DIESEL c❑� T METHANOL 11.7ANKC INTENTS FA IIS MARKED.COMPLETE ITEM C. C. ❑ UNLEADED a GASAHOL ❑ d OIL B' E 1 MOTOR VEHICLE FUEL ICPRL EADE1 PRODUCT ❑ UNLD 5 JET FUEL A. BO EMPTY ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) 2 PETROLEUM ❑ 2 WASTE 95 UNKNOWN C.A.S.R: 3 CHEMICAL PRODUCT p IF(A.t)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED MARK ONE ITEM ONLY IN BOXES AB.AND C.AND ALL THAT APPLIES IN BOX D❑ 95 UNKNOWN 111. TANK CONSTRUCTION ❑ 3 SINGLE WALL WITH EXTERIOR LINER OTHER ❑ I DOUBLE WALL ❑ 0 go A. TYPE OF a SECONDARY CONTAINMENT (VAULTEDTANK) SYSTEM ❑ 2 SINGLE WALL ❑ 3 FIBERGLASS ❑ 4 STEEL LAD NOL C MPA IB REINFORCED PLASTIC ❑ I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 9 TOGA. MET/U1NOL COMPATIBLE WIFRP 7 ALUMINUM B. TANK ❑ 9 POLYVINYL CHLORIDE ❑ ❑ 99 OTHER MATERIAL ❑ 5 CONCRETE ❑ 95 UNKNOWN (PTim9ryTank) ❑ 9 BRONZE ❑ t0 GALVANIZED STEEL a PHENOLIC LINING ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ ❑ 1 RUBBER LINED El 96 UNKNOWN ❑ 9D OTHER ❑TERIOR 5 GLASS LINING El UNLINED C.WINING LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— ❑ a FIBERGLASS REINFORCED PLASTIC ❑ 2 COATING ❑ 3 VINYL WRAP O t POLYETHYLENE WRAP ❑95 UNKNOWN ❑ 99 OTHER D.CORROSION 5 CATHODIC PROTECTION ❑ 91 NONE PROTECTION ❑ BLE A U 3 GRAVITY OR U IF A U 99 OTHER IV.PIPING INFORMATION CIRCLE AIFABOVE AUUZPRESSURENDERGROUND.BOTHIFAPPUCA 1 SUCTION 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER A. SYSTEM TYPE A U A U 2 pOUBLE WALL A U B. CONSTRUCTION A U 1 SINGLE WALL 3 POLW - CHLORIDE(PVC)A U 4 FIBERGLASS PIPE i BARE STEEL A U 2 STAINLESS STEEL A U A U A U 6 CONCRETE A U 7 STEEL WI COATING A U B 1009. METHANOL COMPATIBLE W/FR C. MATERIAL AND 95 UNKNOWN A U 99 OTHER SI U 5 ALUMINUM CORflOSION 10 CATHODIC PROTECTION A U IAL yq OTHER— PROTECTION A U 9 GALVANIZED STEEL A U ❑ 2 LINE TIGHTNESSTESTING ❑ 3 MONITORING ❑ D. LEAK DETECTION ❑ I AUTOMATIC LINELEAK D'cTECTOR V.TANK LEAK DETECTION 3 VAPOR MONITORING❑ a AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 2 INVENTORY RECONCILIATION ❑ ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 VISUAL CHECK ❑ 91 NONE ❑ 6 TANK TESTING ❑ T INTERSTMALMONITORING ❑ MATION 3.WAS TANK FILLED WITH YES L] NO Vi.TANK CLOSURE INFOR ❑ 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIAL? ,.ESTIMATED DATE LAST USED(MOIDpY/YR) SUBSTANCE REMAINING �_ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND 7RUiANO CORRE TO THE BEST OF MY KNOWLEDGE, IS DATE APPLICANTS NAME V IPaxrEO R SIcxRTUAFj LOCAL AGENCY USE ONLY THI.D E STATE .NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK 9 FACILITY# COUNT`!# JURISDICTION Q v' _ 6L STATE LD.# PERMIT EXPIRATION DATE PERMIT APPROVED SYMATE PERMIT NUMBER FORMS IS 9q THIS FORM MU T BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORM A HAS BEEN FILED. �1YA I F } 444444 E