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STATE OF CAUFO <br /> STATE WATER RESOURCES CONTROL BOARD • <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•F 'e6Oun <br /> COMPLETE <br /> MARK ONLY ETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> ONE ITEM 1 NEW PERMIT -e'.. <br /> ❑ 2 INTERIM PERMIT ❑ 3 RENEWgL PERMIT <br /> DBA OR FACILIo' <br /> ❑ 4 AMENDED PERMIT 5 CHANGE OF INFORMATION <br /> TY NAME WHERE TANK IS INSTALLED; ❑ 6 TEMPORARY TANK CLOSURE ❑ Z PERMANENTLY CLOSED ON SITE <br /> I. TANK DESCRIPTION ❑ 6 TANK REMOVED <br /> A. OWNER'S TANK I.D., COMPLETE ALL ITEMS—SPECIFY U <br /> IF UNKNOWN <br /> C. DATE INSTALLED(Mp/DAY/YEARI <br /> B. MANUFACTURED BY: <br /> If.TANKCONTENT$ D. TANK CAPACITY IN GALLONS: <br /> IFA-1 L4MARKED,CpMPLETEITEMC. <br /> A. o-1'18iSTOR VEHICLE FUEL ❑ 4 OIL <br /> ❑ 2 PETROLEUM B. <br /> BO EMPTYC. fa REGULAR <br /> ❑ 3 CHEMICAL PRODUCT 1 PRODUCT UNLEADED 3 DIESEL <br /> 95 UNIOOWry ❑ ib PR IUM L_J 4 GASAHOL ❑ 6 AVIATION GAS <br /> D. IF(p.1)IS NOTMARKED, ENTER NAME aF ❑ 2 WASTE <br /> SUBSTANCE STORED L1 2 LEADED D 5 JETFUEL ❑ T METHANOL <br /> III. TANK CONSiRUCTI N ❑ 99 OTHER (DESCRIBE IN ITEM D. SELOWI <br /> MAI6CONE ITEM OMLY N BOXES A,S, C.A.S.x; <br /> A. TYPE OF ❑ ANWITH E RIOR LINER ES IN BOXD <br /> DOUBLE WALL ❑ 3 SINGLE WALL WITH <br /> SYSTEM 2 GLE WALL EMEN OR LINER <br /> ❑ 4 SECONDARY CONTAINMENT ❑ a'` UNKNOWN <br /> (VAULTED TAN <br /> 1 BARE STEEL K) ❑ 99 OTHER <br /> B. TANK ❑ 2 STAINLESS STEEL <br /> MATERIAL ❑ 5 CONCRETE 8 POLYVINYL CHL ED 3 FIBERGLASS ❑ <br /> PRM ED STEEL CLAD W/FIBERGLASS R <br /> EINFOR <br /> (PdmaryTe9K( F-19 BRONZE ❑ 10 GALVANIZED STEEL ❑ T ALUMINUM ❑ g '0011METHANOL COMPATIBLE W/FRI,CED PLASTIC <br /> 95 UNKNOWN <br /> ❑ 1 RUBBER t)® ❑ 2 Al LINING <br /> �EE�pppp�pA� ❑ � OTHER <br /> G.INTERIOR F-1MIG 5 GLASS L ❑ ❑ OXY LINING <br /> LaWD 6 UNLINED afi UNKNOWN E] 4 PI�NOLK: LINING <br /> B LINING MATERIAL CdATIaE WRH 100% METTNIgLp YES_ NO ❑ go OTHER <br /> D.CORROSION ❑ T Poll <br /> AP ❑ 2 COATING <br /> PROTECTION E] 5 CATHODIC TK1N❑ 91 NOW 3 L WRAP ❑ 4 FIBERGLASS REINFORCED <br /> 95 UNKNOWN PLASTIC <br /> A. PIPING INFORMATION CI IFgBOVEGROLApg1 U FUNDERGROUND,80TH IFAPPLICABLE❑ 99 OTHER <br /> A. SYSTEM TYPE sucnc A U 2 PRESSURE <br /> B. CONSTRUCTION A U 1 SINGLILA U 3 GRAVITY <br /> A U 2 DOUBLE WgLI A U 3 LINED TRENCH q U 1M OTHER <br /> A U 1 BARE A U 2 STAINLESS S q U 3 <br /> C. MATERIAL AND TEEL U UNKNOWN <br /> CORROSION A U S ALUM A U 6 CONCRETE STEE VL CHLORIDE PVO A U OTHER <br /> lA U d FIBERGLASS PIPE <br /> PROTECTION A U 9 GALV STEEL A U 10 CATHODIC PROTECT ON T S7�/SATING q U <br /> 1 AUTO ELEAK DETECTOR U UNKNOWN 8 10095 METHANOL COMPATIBLEW/FRP <br /> D. LEAK DETECTION ❑ IN <br /> 1 — ❑ 2 LINE TIGHTNESS TESTING 31NTERSTI IALU 99 OTHER <br /> V.TANK LEAK DETECTION MDNTOTTING ❑ 99 OTHER <br /> ❑ 1 VISUAL CHECK E] 2�qy RECONCILIATION Tff 3 VAPOR MONITORING <br /> 6 TANK TESTING 7TITIAL MONITORING <br /> ❑ ❑ AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 61 NONE <br /> e6 <br /> VI.TANK CLOSURE INFORM— UNKNOWN 1-7 99 OTHER <br /> 1.ESTIMATED DATE LAST UBED(MOI 2.ESTIMg7ED QUANTITY OF <br /> SUBSTANCE REMAINING 3.WAS TANK FILLED WITH <br /> UNDER �GAIIONS INEgTMATERIAL9 YES <br /> THIS FORM HAS BEEN C' ER DEN <br /> APPLICANTS NAME AL7Y OF PERJURY,AND TO THE BEST OF MY K ❑ No <br /> IPRINTE9 B SIGNaTUH61 NOWLEDGE, IS TRUE AND CORRECT <br /> DATE <br /> LOCAL AGENCY USE 01111STATE I.D,NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTYx JURISDICTION# <br /> STATE I.D.# FgCILITYq <br /> TANK# �^'-u^w <br /> PERMITNUMBER P RM ITA /!.�l <br /> ANIED BY <br /> ACCQMP PERMIT EXPIRATION DATE G <br /> FORM B (9-90( THIS FOI A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORMA HAS BEF Z7 <br /> FILED. <br /> ' roR9fmo6.6e <br />