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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL 30ARD ^^ ate ., UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM 3 ,Ia 0 COMPLEi.A SEPARATE FORM FOR CN TANK SYSTEM. �'`'-�^ MARK ONLYI NEW PERMIT 0 RENEWAL PERMIT 5 CHNG AE OF INFORMATION ❑ ❑ L] ❑ RMANENTI.Y CLOSED ON S(r ONE ITEM ❑ 2 INTERIM REKNIT ❑ n AMENDED PERMIT n e TEMPORARY TANK CLOSURE 1 3 TANK REMOVED 08A OR FAC,LITY NAME'WHERE TANK IS INSTALLED: lv / I. TANK DESCRIPTION COMPLcTEALLITEMS- SPECIFYIFUNKNOWN v / i A OWNER'S TANK 1.0.s O � i MANUFAC'URED aY: U�Ic, C. GATE INSTALLO(MCVOAYA'EAR) u/� I 0. TANK CAPACITY :N GALLONS: It.TANK CO ENTS :FA-I IS MARKED.COMPLETEITEM G I MOTOR vE}HICLE FUEL ❑ a CL I a, I G ❑ la REGALIA A DIESEL ❑ d AVIATK7N GAS uNtuweD C _ ❑ 2 PETROLEUM ❑ 30 EMPTY I PRODUCT ❑ 10 PREMIUM a CI ❑ 75IETHANCL UNLEADED 15 :ET FUEL CI 7 CNEMIGLPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEACED j 39 OTHER rcesc 19E IN ITEM D. 9ELOM 0. IF(A.I)ISNCTMARKEO. ENTER NAME OF SUBSTANCE. STORED b C.A. III. TANK CONSTRUCTION MARKCNE �c.M ONLY IN 90XESA.3.AND G AND ALL THATAPPLIES:N 00X0 A. TYPE OF ❑ DOUBLE 'WALL ❑ 9 SINGLE 'WALL WRH EXTEaICA LINER ❑ 95 UNKNOWN SYSTEM SINGLE 'NALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK ❑ 99 OTHER S. TANK _ I BARE STEL ❑ 2 STAINLESS STEEL ❑ 9 FIBERGLASS ❑ A STEEL."'..AO 'NI F SEAGLASS REINFORCED PLAS7c MATERIAL ❑ 5 CONCRETE CI 8 PCLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 3 ;DPA MET}iANCL COMPATIBLEWIFRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVAW= STEEL ❑ 95 UNKNCWN r j N OTHER 1 RUBBER LW© ❑ 2 ALKYD LNING ❑ 7 EPDXY LINING ❑ a PHENCLG LINING O.INTERIOR j s GL.15S LINING uNLWEO ❑ 35 UNKNOWN ❑ 99 OTHER L� IS LINING MATERIAL CCMPATSLE WITH 100% METHANOL? YES— // NO_ 0.CORROSION ❑ I POLYETHYLENE WRAP I❑ 2 COATING VINYL WRAP ,7 a FIBERGLASS REINFORCED PUSTC PROTECTION ❑ 5 CATHODIC PROTECTION I❑ 91 NONE 95 UNKNOWN ❑ 99 OTHER . IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND OR U IF UNCERCROUNI 30TH IF APPLICAaUE A. SYS,cM TYPE U 1 SUCTI A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 3. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE'NALL A U 9 LINED TRENCH A A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORCE(PVC)A U A PSEACLASS PIPE CORROSION A U 5 ALUMINUM A U 5 CCNCAE79 A U 7 - A U 3 100% METHANOL COMPATIBLE'WIFRP PROTECTION A u g GALVANIZED srEEt A u Io GTHCDICPPoTECTICN U 95 UNKNOWN A U 99 OTHER 0. LEAK OETECTION ❑ I AUTOMATIC LINE LEAK OETECTCR 2 LINE TIGHTNESS TESTING ❑ 4MOINfCRMG 1-'T N OTHER V.TANK LEAK DETECTION LJ ❑ I VISUAL CHECK 2 INVENTORY RECONCLATON ❑ U VAPOR MONITORING❑ n AUTOMATIC TANK GAUC¢NG ❑ 5 GROUND WATER MGNITCRING ❑ 8 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UM04CWN ❑ W OTHER VI.TANK CLOSURE INFORMATICN 1.E5^MATED CATE LAST USED(MOIOAYNR) 2.ESTIMATED CAANTTTY OF 1 WAS TANKFUL-[)WTfH SUBSTANCE REMAINING C%UCNSE I �NERTMARMYES L? ❑ ❑ THIS FORM HAS BEEN COMPL`IE'D UNDER PENALTY OF PERJURY,AND TO 774E 9EST OF,WY KNOWLEDGE—IS TRUE AND CORRECT APPL;CANrS NAME IPfbMEO!SIGNAtUPq OATZ c LOCAL AGENCY USE ONLY THE STATE LD.NUMBER IS COMPOSED OF THE FOURNUMBERS BELOW A' / COUNTY x JURISDICTION S FACILITY x TANK STATE 1.0.# X31 S10 / I l 7 lo yIt PERMIT NUMBER I PERMIT APPROVED BY(CATE PERMIT EXPIRATION OATS FORM 3 14301 THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. �h `