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�SpURCES <br /> P Cp <br /> r - ? <br /> STATE OF CALIFORNIA x <br /> STATE WATER RESOURCES CONTROL BOARD w ;� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM 13 <br /> `—� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY SITE <br /> ONE ITEM El 2 INTERIM P PERMIT 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TFNK REMOV Dc <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> B. MANUFACTURED BY: <br /> A. OWNER'S TANK I-D.# <br /> VAL— <br /> C DATE INSTALL (MOOAY/YEAR) <br /> D. TANK CAPACITY IN GALLONS: <br /> II.T blK NTENTS IFA-1 IS MARKED.COMPLETE ITEM C. ❑ taREGULAR 3 DIESEL <br /> 1 MOTOR VEHICLE FUEL 4 OIL B. C. AVIATION OLAS <br /> MIL <br /> A I UNL ED 4 GASAHOL a <br /> O 2 PETROLEUM <br /> O 80 EMPTY 1 PRODUCT 1b NLEADED a 5 JEMIUM T FUEL <br /> 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW <br /> U 3 CHEMICAL PRODUCT U 95 UNKNOWN U ) <br /> D. IF iA-1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S-A <br /> III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX D <br /> A. TYPE OF <br /> 1 DOUBLE WALL M 3 SINGLE WALL WITH EXTERIOR LINER EJ 95 UNKNOWN <br /> SYSTEM a 2 SINGLE WALL a 4 SECONDARY CONTAINMENT (VAULTED TANK) O 99 OTHER <br /> El 1 BARE STEEL 2 STAINLESS STEEL El 3 FIBERGLASS a 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> B. TANK 6 POLYVINYL CHLORIDE a 7 ALUMINUM 8 100°/ METHANOL COMPATIBLE W/FRP <br /> MATERIAL 5 CONCRETE <br /> (Primary Tank) 9 BRONZE O 10 GALVANIZED STEEL 95 UNKNOWN a 99 OTHER <br /> El 1 RUBBER LINED a 2 ALKYD LINING F-] 3 EPDXY LINING O 4 PHENOLIC LINING <br /> C.INTERIOR F-1 5 GLASS LINING El 6 UNLINED D 95 UNKNOWN 99 OTHER <br /> '.INING <br /> IS LINING MATERIAL COMPATIBLE WITH 100°/ METHANOL? YES_ NO_ <br /> u , POI YETHYLENE WRAP F---1 2 COATING GI 3 VINYL WRAP El 4 FIBERGLASS REINFORCED PLASTIC. <br /> D.CORROSION <br /> PROTECTION E:] 5 CATHODIC PROTECTION [::] 91 NONE 95 UNKNOWN El 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 2 PRESSURE A U 3 GRAVITY d 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 W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION [::] 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 0 3 INTERSTITIA <br /> NTERS I GL � 99 OTHER <br /> MONITV.TANK LEAK DETECTION <br /> M 1 VISUAL CHECK O 2 INVENTORY RECONCILIATION O 3 VAPOR MONITORING a 4 AUTOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> El 6 TANK TESTING F-1 7 INTERSTITIAL MONITORING O 91 NONE u 95 UNKNOWN E:l 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES D NO <br /> 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 /> (PRINTED b SIGNATURE) / <br /> I -� — 9-- r�. <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF,T14E FOUR NUMBERS BELOW \� <br /> F- <br /> sWTY�/A";/ COUNTY# JURISDICTIOONNW/ FACILITY# TANK#kw <br /> MIT NUMBER PERMIT APPROVED B ATE "PERMIT EXPIRATION DATE <br /> FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLI ION-FORM A,UNLESS A CUR NYFORM A HAS BEEN FILED. <br /> �/f FOR00345-R4 <br />