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�,nw�cz STATE OF CALIFORNIA r cO STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 6 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY J 1 NEW PERMIT CI 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ON SITE ONE ITEM ❑ 2 INTERIM PERMIT C! 4 AMENDED PER".UT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED; SCA (�G 1'C (DS t 6 1. TANK DESCRIPTION COMPLETE ALL ITEMS^ SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.tl 2 B. MANUFACTURED BY: X `G�S C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLONS: 1 2 v C) II.TANK CONTENTS IF A-1 IS MARKED,COMPLETE ITEM C. Z 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. j C ❑ •a REGULAR UNLEADED ❑ 3 DIESEL ;_J 6 1 PRODUCT AVIATICNGAS L17 PREMJUM UNLEADED ❑ 4 GASAHOL E] 7 METHANOL 177 2 PETROLEUM 80 EMPTY i —1 Ir, MIDGAADE UNLEADED C, 5 JET FUEL ❑ 8 M65 ❑ 3 CHEMICAL PRODUCT n 95 UNKNOWN ❑ 2 WASTE ❑ Z LEADED C 99 OTHEa;OESCRIBE IV ITEf.I D.BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.k: 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BCXES A.B.AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ;� 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE a 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 1G0% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ g BRONZE ❑ 10 GALVANIZED STEEL L_I 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING 4 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING 6 UNLINED 7 95 UNKNOWN 1 7 99 OTHER COATING 15 LINING MATERIAL COMPATIBLE WITH 1001A METHANOL? YES_X_ NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ; 4 FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION E] 91 NONE ❑ 95 UNKNOWN - OTHER E.SPILL AND OVERFILL,EtC, SPILL CONTAINMENT INSTALLED(YEAR) OVER.FILLpREVENT;ON ECUIPMENT;NSTALLED(YEAR) DROP TUBE YES�_ NO STFIKER PLATE YES X N'O DISPENSER CONTAINMENT YES NO IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSUpE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A l)2 DOUBLE WALL A U 3 LINED TRE14CH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A&4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WlFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 MECHANICAL UNE LEAK [:]2 UNE TIGHTNESS (��"�3 CCNTN'UCUS PTERSrTIAL 4 ELEMCNIC UNE 5 AUTOMATIC PUMP gg OT1iER —�.,. ^ D. LEAK DETECTION ® DETECTOR TESTING MOMTCRNG ❑ LEAr C�cTOR srur�ovn+ ❑ V.TANK LEAK DETECTION n 2 MANUAL INVENTORY 3 VADOZE �II 4 AUTOMATIC TANK 5 GROUND WATER E 6 ANNUALTANK _ 1 VISUAL CHECK ❑ RECONCILIATION �--� MONITORING J GAUGING MONITORING TESTING (� 7 CONTINUOUS INTERSTITIAL ❑ g SIR ❑ 9 WEEKLY MANUAL I❑ 10 MONTHLY TANK J 95 UNKNOWN 99 OTHER MONITORING TANK GAUGING TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(.VNO/DAY,-YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH :YES SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME DATE (PRINTED 8 SIGNATURE) \\\ f1j� 2 LOCAL AGENCY USE ONLY THE STATE`I.D.NUMBER IS COMPOSED OF THE FOUR MBER BELOW COUNTY 4 JURISDICTION# F CILITY TANK 1t STATE I.D.# _7T_ j PERMIT NUMBER 1 PERMIT APPROVED BY,'DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLAN. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FCRM B (6-95)