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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - R <br /> 5 199 �=® � • o <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. "°""•". <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION PEJ f&; EIS ED <br /> LOSE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK OV /f0 <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /�j L/n/D 6� �O .✓ LJzQ�� <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNERS TANK I.D.8 B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MOIDAYIYEAR) _ / D. TANK CAPACITY IN GALLONS: t/O OD <br /> ILTANKCONTENTS IFA-11SMARKED.COMPLETE ITEM C. <br /> A �1 MOTOR VEHICLE FUEL O 4 OIL B. C. 0 1a REGULAR <br /> /-� 4 DDIESEGASAFLIOL Q 6 AVIATION GAS <br /> 2 PETROLEUM O BO EMPTY 1 PRODUCT Ej 1ePREMIUMUNLEADED 0 5 JETFUEL ❑ 7 METHANOL <br /> O 3 CHEMICAL PRODUCT O 95 UNKNOWN 2 WASTE O 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.N: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX <br /> A. TYPE OF1-1 UBLE WALL O 3 SINGLE WALL WITH EXTERIOR LINER O 95 UNKNOWN <br /> SYSTEM 2 GLE WALL Q 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> B. TANK Eirl BARE STEEL 0 2 STAINLESS STEEL 0 3 FIBERGLASS O 4 STEEL CLAD N FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL = 5 CONCRETE 6 POLYVINYL CHLORIDE O 7 ALUMINUM O 6 100% METHANOL COMPATIBLE W/FRP <br /> (PrimaryTank) O 9 BRONZE 0 10 GALVANIZED STEEL 95 UNKNOWN 0 S9 OTHER <br /> O 1 RUBBER LINED O 2 WING O 3 EPDXY LINING 4 PHENOLIC LINING <br /> G.INTERIOR <br /> LINING O 5 GLASS LINING 6 UNLINED O 95 UNKNOWN O 99 OTHER <br /> 19 LINING MATERIAL COMPATIBLE WITH 1 ETHANOL 7 YES— NO_ <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING O 3 VINYL WRAP O 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION O 5 CATHODIC PROTECTION O 91 NONE O 95 UNKNOWN O 99 OTHER <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 A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U SI A A2 DOUBLE 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 <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 1 THANOL COMPATIBLE WIFRP <br /> PROTECTION A U 9 GALVANI STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION Q 1 AUTOM LINE LEAK DETECTOR O 2 LINE TIGHTNESS TESTING O 31NTEASTDML 99 OTHER <br /> MONITORING <br /> V.TANK LEAK DETECTION <br /> 0 1 VISUAL CHECK 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING 0 4 AUTOMATIC TANK GAUGING a 5 GROUND WATER MONITORING <br /> 0 6 TANK TESTING O 7 INTERSTITIAL MONITORING O 91 NONE O 95 UNKNOWN O 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED O/D V/VR) 2.ESTIMATED WANTITV OF 3.WAS TANK FILLED WITH YES NO <br /> y SUBSTANCE REMAINING GALLONS INERT MATERIAL? <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> IPRINTE9 4 SIG NATUREI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY III TANK# <br /> STATE I.D.# F3TI I S <br /> PERMIT NUMBER PERMIT APPROVED BY/DATE PERM IT EXPIRATION DATE <br /> FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOROW48-RI <br />