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• -`iJu-CtJ STATE OFCALIFORNIA +.'" w'' •' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM S . ' i ry- CCLP_-A SEPARATE FORM FOR EA ANK SYSTEM. i MARK ONLY ❑ t NEW PERMIT ❑ 3 .e4svAL PERMIT 5 CHANGE CF INFORMATION ❑ 7 PER ANENTLY ONE REM ❑ 2 INTERIM PERMIT ❑ + M19CM PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 6 TA REMOVED j DBA OR FACILITY NAME WHERE TANK IS INSTALLED: ) I. TANK DESCRIPTION co _ETEALLITEMS- xUNKNOWN A. OWNEF'S TANK L 0.i I S. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) :2 0. TANK CAPACITY IN GALLONS: ll.TANK CONTENTS IF:A-I ISMARKED.CC - —7+c L) I M Y( I MOTOR VEHICLE FUEL cffa OL 3, C. ❑ la REGULAR A. 01 ❑ W► GAS UNLEAD❑ 2 PETROLEUM ❑ 80 3gY � PRODUCT ❑ ib PREMIUM a GASAHOL c- 3 7 METTIANCL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 uN*dCwN I ❑ 2 WASTE ❑ 2 LEADED El 99 OTHER (DESCRIBE IN ITEM 0.3ELCW1 D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE a.CRED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONL-f x 30XES A.B.AND C.AND ALL THAT APPLIES IN BCX 0 A. TYPE OF ❑ DOUBLE WALL 3 Sv=-WALL WITH EXTERIOR LINERI�❑ 95 UNKNOWN SYSTEM 2 LE WALL C s s`.CrNOARY CONTAINMENT (VAULTEDTANK► 1 99 OTHER I BARE STEEL C 2 �.AWI=SS STEEL ❑ 3 FIBERGLASS ❑ a STEEL CLAD W/FIBERGLASS REINFORCo PL,%STIC 8. TANK 5 ?CL-VLNYL CHLORIDE 7 ALUMINUM 3 1007E METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE � ❑ �f (Primary Tank) ❑ 9 BRONZE XZ GALVANIZED STEEL. ❑ 95 UNKNOWN ❑ 99 OTHER ❑ t RUBBER LINED 2 AL:iYO LSIING ❑❑ 3 EP91CY LINING ❑ A PHENOLIC LINING C.INTERIOR S GLASS LINING � 3 uvamE,7 UNKNOWN LINING �--I C ❑ 99 OTHER LS LINING MATERIAL COMPATMLS- V97A =%METHANOL? YES_ NO 1 POLYET I.-INE WRAP 2 ,rATINC a FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑ C 0 PROTECTION ❑ s CATHODIC PROTECTION I + 9t NCIVE ��UNKNOWNAP ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFABCVEYI=40CR U IFUNDERGROUND.BOTHIFAPPLICAZLE A. SYSTEM TYPE A U t SUCTION A 3 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U t SINGLE WALL A 3 2 DCUSLE WALL A U 3 LINED TRENQ4 A U 95 UNKNOWN A u 99 OTS C. MATERIAL AND A U I BARE STEEL A 3 2 STAINLESS STEEL A U 3 POLYVINYL CHL.ORICE(PVC)A U • FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A 7 5 CONCRETE A U 7 STEEL WI COATING A U 6 100% METHANOL COMPAT3L---W/FRP PROTECTION A U 9 GALVANCED STEEL A 3 t0 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER r DETECTION ❑ I AUTOMATICLINEL EAK:k a- :. R ❑ 2 UNETIGHTNESSTESTING ❑ 3 99 OTHER ❑LEAK DETECTION ISUAL CHECK 2 INVENTORY RECL +C:ATICN ❑ 3 VAPOR MONITORING❑ t AUTOMATIC TANK GAUGING❑ 5 GROUND WATERANK TESTING ❑ 7 INTERSTRTALMON: RINIM ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER . CLOSURE INFORMATION t.ESTIMATED DATE LAST USED(MO/OAY/YR) j Z ESTIMATED OUANTRY OF 3 WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERT MATERIAL? YES ❑ 40❑ THIS FORM HAS BEEN COMPLETED UNDE-i rE'VALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CCRRECT APPLICANTS NAME DATE (PAINTED&S"ATUaq I 6-Y,�J/, LOCAL AGENCY USE ONLY THE STATE LD.-4tWE9 IS COMPOSED OFTHE FOUR NUMBERS BELOW - % COtN-4v,. XRISOICTIQV x FACILITYj FACILITY' TANK STATE I.D.n PSAMIT NUMBER j PE=.WT APPROVED BYIDATE I PERMIT EXPIRATION DATE FORM B (9.90) THIS FORM MUST BE ACCOMPANIED EY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOPA=S-s