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WASTE OIL S SIATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> n I UNDERGROUND STORAGE TANK PERMIT APPLIICA <br /> ENVIRONMENTAL HEAL <br /> v COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM.pE g M I ' I �c <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED oN SITE <br /> MARK ONLY Q ❑ 4 AMENDED PERMIT ❑ B TEMPORARY TANK CLOSURE ❑ S TANK REMOVED <br /> ONE ITEM 2 INTERIM PERMIT <br /> DBAOR FACILITY NAME WHERE TANK IS INSTALLED: 2526 W. Washington St., Stockton, CA 95203 <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> TEL MANUFACTURED BY: Modern Welding Co-STI-P3 <br /> A. owNER•S TANK I.D.# UL#J-351645STI-P3 #7946 <br /> D. TANK CAPACITY IN GALLONS: 1,000 <br /> C. DATE INSTALLED(MO/DAYNEAR) 11/11/67 <br /> II.TANK CONTENTS IFA-11SMARKED,COMPLETE ITEM C. 1a REGULAR T74 <br /> SEL ❑ 6AVIATION GAS <br /> ❑ 1 MOTOR VEHICLE FUEL ® 4 OIL B. C. ❑ UNLEADED �AHpL ❑ 7 METHANOL <br /> A ❑ W EMPTY ❑ 1 PRODUCT ❑ 1bUNLEADEDPREMIUM T FUEL2 PETROLEUMJUM <br /> 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ® 2 WASTE ❑ 2 LEADED THER (DESCRIBE IN ITEM D. BELOW) <br /> c.as.a: N/A <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED Waste. 011 <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C,AND ALL THAT APPLIESIN BOKD <br /> ® 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 85 UNKNOWN <br /> A. TYPE Of ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER <br /> SYSTEM ❑ 2 SINGLE WALL <br /> ® 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ ♦ STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 5 CONCRETE ❑ 6 POLININVL CHLORIDE ❑ 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE WIFRP <br /> MATERIAL ❑ <br /> (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> C.INTERIOR O 5 GLASS LINING ❑ 6 UNLINED ® 96 UNKNOWN ❑ 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL 7 YES— NO_ <br /> ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PflOTECTXNJ ❑ 91 NONE <br /> D. <br /> El 96 95 UNKNOWN 99 OTHER <br /> P ® <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U a 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A©10 CATHOOICPROTECTKJN A U 95 UNKNOWN A U 99 OTHER <br /> ERSTITAL AUTOMATIC LINE LEAK DETECTOR ® 2 LINE TIGHTNESS TESTING ❑ 9IMMONRORING ❑99 OTHER <br /> D. LEAK DETECTION ❑ 1 _.-. <br /> V.TANK LEAK DETECTION <br /> M❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING O 7 INTERSTITIAL MONITORING E] 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAV/YR) 2.ESTIMATED OJANTITY OF 3.WAS TANK FILLED WITH YES NO <br /> SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ ❑ <br /> THIS FORM HAS BEEN COMPLETED U ER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME /7' DATE <br /> (PRINTED A SIGNATURE) Richard A. Recor 1"' 8/20/91 <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTK)N# # TANK# L <br /> STATE I.D.# � oZ S11011 (yp�I <br /> PERMITNUM13ER PERMIT APPROVED BY/DATE IT EXPIRATION DATE e <br /> FORMS (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. Y <br /> FORSIX B-R4 <br />