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• SFATEOFCAUFORNA ;��•/� j�� '`6��•. °^ STATE WATER RESOURCES CONTROL BOARDI'Jllyll_�II� III I Qy g UNDERGROUND STORAGE TANK PERMIT APPLI FORM Y_ COMPLETE A SEPARATE FORM FOR5A09 TANK SYSTEM.,, 2 U 1991 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ,E 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLO UgE.E�I}�O RE ip%i REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: PEf� 1 Wm.fl H� I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.0.N B. MANUFACTURED BY.. C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. A. [ MOTOR VEHICLE FUEL ❑ 4 OIL B. O. laIREG ED 3 DIESEL ❑ g AVIATIONGAS ❑ 2 PETROLEUM ❑ 80 EMPTY PRODUCT ❑ ib PREMIUM 4 GASAHOL ❑ 7 METHANOL ❑ D O 99 JOTHER (DESCRIBE IN ITEM D. BELOW)L ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN E::] 2 WASTE UNLEADED 2 LEADED D. IF(A.1)IS NOTMARKED, ENTER NAME OFSUBSTANCE STORED C.A.S.#: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXESA.B,AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF �❑�/11 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN L SYSTEM IS 22 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER a B. TANK RARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTaak) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTE NOR ❑ 5 GLASS LINING ©UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LIN IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP 2 COATING ❑ 9 VINYL WRAP ❑ q FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABOVEGROUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U- 1 SUCTION A(Z)2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION 11 SINGLE WALL A U 2 DOUBLE WALL A U 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)A U 4 FIBERGLASS PIPE CORROSION A U S ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A 92EALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 31NTEAS WL ❑99 OTHER MONRORING V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAVA'R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH NO SUBSTANCE REMAINING .GAYESLLONS INERT MATERIAL 7 Lrl ❑ THIS FORM HAS BEEN C21&LETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME IP W NTED a SIGNATURE) DATE LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# U / b S o d o U PERMIT NUMBER III ERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORo=B(alM L