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O�A SKIMMER TANK �` STATE OF CALIFORIA '"STATE WATER RESOURCES CONTROL BOARD �� *" ��UNDERGROUND STORAGE TANK PERMIT APPLICATION-A915"3 19COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM,r'�V� 0NMENTAL1 MARK:EITEM ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATI N ' MP EN V CLOSED 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ B TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.a UL# J-396660 STI-P3 B. MANUFACTURED BY: Highland Tank & Mfg. Co. C. DATE INSTALLED(MOA7AY/YEAK) 11/11/87 D. TANK CAPACITY IN GALLONS: 500 ILTANKCONTENTS IFA-11SMARKED.00MPLETE ITEM C. to REGULAR 3 DIESEL ❑ aAVIATIONGAS 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. O. ❑ UNLEADED 4 GASAHOL Q A ❑ 2 PETROLEUM ® BO EMPTY ❑ 1 PRODUCT ❑ 1bUNLEAIDED ❑ 5 JET FUEL 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ® 2 WASTE ❑ 2 LEADED ® W OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED Waste Oils c.A.s.#: N/A 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOXD O 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF99 OTHER SYSTEM E] 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ KI 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK F--] 00 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1 % METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR O 5 GLASS LINING O 6 UNLINED ® 96 UNKNOWN ❑ 99 OTHER LINING IS�JLINING MATERIAL COMPATIBLE WITH 100% METHANOL? VES_ NO— D.CORROSION 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ® 5 CATHODIC PROTECTKJN ❑ 91 NONE ❑95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEMTYPE A U 1 SUCTION A U 2 PRESSURE p 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL AQ 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 p U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE Ao 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL AO 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ J MONITORI GL ❑ OTHER 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/DAYNR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES NO❑ SUB STAN CE REMAINING GALLONS INERTMATERIAL7 THIS FORM HAS BEEN COMPLETED NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRINTED 651GHRTIRE) R3chaY A. ReCox 8/20/91 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# ILITY# TANK# STATE I.D.# all $s 151"-r I I I lolz / PERMIT NUMBER PERMIT 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. FOR�eW BPA