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STATE OF CALIFORNIA e�„"t•• �`L <br /> STATE WATER RESOURCES CONTROL BOARD <br /> - UNDERGRO0116 STORAGE TANK PERMIT APPLICATIO'l-FORMS r aIa <br /> COMPLei E A SEPARATE FORM FOR",3CH TANK SYST"ea.1 <br /> MARK ONLY ❑ 1 NEW PEAMIT ❑ 3 aoisw& PERMIT S CHANGE OF INFORMATION ❑ PERMANENnY�CLCSED ON LTE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE Cff 8 TANK REMOVED <br /> OBA OR FACILITY NAME WHERE TANK IS INST�LUq: <br /> I. TANK DESCRIPTION COMPLETE ALL Fems -�SPECIFY IFUNKNOWN / \ <br /> A. OWNER'S TANK L 0.s / <br /> 8. MANUFACTURED 8Y: ! ' <br /> C. OATS INSTALLED(MC10AY/Y£AR) ( U 0. TANK CAPACfTY W G ONS: /71 <br /> II.TANK CONTENTS IFA-I IS MARKED.CCMP ITEM C. / V I <br /> A. ❑ I MOTOR VEHICLE FUEL a OIL g C. I-1 IASEGULAA 3 DEEsEL .---` AVtAIICN �, <br /> L! UNLEADED <br /> ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 oQUCT ❑ SauNLEAO S r EL \ <br /> ❑;,7-MMANCL <br /> ❑ 7 CHEMKAL?ROOUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED THEA MESCAIB£ IN ITEM 0. BELOW) <br /> 0. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STC REO <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN aOXES.I a.ANO C.AND ALLTNAT APPLIES IN aox 0 / <br /> A. TYPE OFDOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER Cl95 UNKNO / <br /> SYSTEM � C-]SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) 99 ONea <br /> B. TANK a 1 BARE C:] 2 STAINLESS STEEL ❑ 3 F1aEAGLASS ❑ ♦ STEEL CLAD'N!FIBERGLASS AEfNFOrCcC PL.LSTIC <br /> MATERIAL ❑ S CwMCa>=tE ❑ B POLYVINYL C}{LCRICE ❑ 7 UMWUM ❑ 8 100% METHANCL CCMPATIaLE WSRP <br /> (PrimuYTankl ❑ 9 KRONE ❑ 10 GALVAN290 STEEL C, 45 UNMOWN ❑ 99 OTHER <br /> C. <br /> Fl RUBBER LINED ❑ 2 ALXYO LNING I� 3,ZPDXY LINING ❑ a PNENCL)C LINING <br /> INTERIOR <br /> F—)Fl <br /> M-kSS LINING ❑ 8 UNLINED D-'// <br /> 9S UNKNOWN ❑ 99 OTHER <br /> IS LINING MATERIAL COMPATIBLE WITH 10C% .WET14ANOL7 Y"— Na- <br /> 0.CORROSION ❑ I PCLYETIdYLENE WRAP 0 2 COATING ��;, <br /> WRAP ❑ a rIBI:RGLASS n'EWFORC:EO PLASTIC <br /> PROTECTION ❑ 3 CATHGOK; PROTECTION ❑ 91 NONE UNKNOWN ❑ 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IFAaCVEGACL;NOOR U IFUNCEAGRCUND.aOTHIFAPPLICABLE <br /> A. SYSTEM TYPE A U I SUCTICN A U 2 PRESSURE A U 3 GRAVITY A U 99 OT14ER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNXNCWN A U 99 OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PWG <br /> CORROSION A U 3 ALUMINUM A U B CONCRETE A U 7 STEEL V COATING A V 8 10CX METHANOL COMPAT18L:-:WiFnP <br /> PROTECTION A U 9 GALVANIZED S A U 10 CaTHCCICPROTECTICN A U 95 UNKNOWN A U 99 OTHER <br /> 0. LEAK DETECTION ❑ 1 AUTCMATIC LINE LEAK CE i.CTOR ❑ 2 LINE TIGHTNESS TESTING <br /> ❑ .v 61l ❑ 99 DTrIER <br /> McrlrraalrlG <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 NVENTORY RECCNC2.IArCN ❑ 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING❑ S WOUND WATEa MCNITCAING <br /> ❑ 8 TANK TESTING ❑ 7 NM;;STTTUILMONITCRING ❑ 91 MCN£ ❑ 93 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> I.ESTIMATED DATE LAST USED 0AWAY(YR) 2.ESTIMATEO CUANTITY OF 3.WAS TANK F LLED WTTH <br /> SUBSTANCE REMAINING GALLONS INERTMATEAIAL 7 YES ❑ Na C:] <br /> THIS FARM HAS BEEN COMP LE i ED UNDER PENALTY OF PF•RJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT <br /> APPLICANTS NAME <br /> IvapT60 a SIGMAflNFp DATE <br /> LOCAL AGENCY USE ONLY THE SIE LLD.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW �j✓ <br /> /�(//f <br /> COUNTY* JLIRiSOICTION s FACILITY s TANK x <br /> STA E La.# JJ (j`[�� Q D ' � � �F l <br /> PEnMiTVUMBEa I PERMIT APj�ROVED BBYYICAlTE P`SMITEXPIRATION DATE / <br /> } <br /> FORM a (9.90) THIS FORM MUST BE A MPANIED B"PERMIT APPLICATON•FORM A.UNLESS A CU RM FORM A HAS BEEN FILEX' <br /> FOAOCSIB-0.L <br />