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STATE OF CAUFOFMA t STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERM APPLICATION-FORM 8 ° CO A SEPARATE FORM FO CH TANK SYSTEM. MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT L.J 5 CHANGE OF INFORMATION �L/=Z� TMC76133---)NTLY SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2G!irtYja I I. TANK DESCRIPTION COMPLETE ALL ITEM -SPECIFY IF UNKNOWN A. OWNERS TANK 1.D.s 11 IU► ( fA 4.-;' -0-5 ( B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) LIr1kila-m 0. TANK CAPACITY IN GALLONS: 11.TANK CONTENTS IF A-1 IS MARKED.COMPLETE ITEM C. REGULARA t MOTOR VEHICLE FUEL ® 4 OIL B. C. ❑ la aUNLEADED 3 DIESEL ❑ g AVIATION GAS ❑ 2 PETROLEUM ❑ So EMPTY Cg 1 PRODUCT lb PREMIUM 4 GASAmOL ❑ 7 METHANOL UNLEADED 5 JET FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ® 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLES IN BOX 0 AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ® 0 OTHER j B. TANK t BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLAsT1C MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL,CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimwyTuik) 1 g BRONZE ❑ 10 GALVANIZED STEEL ^ 85 UNKNOWN n 88 OTHER 1 RUBBER LIVED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ® A PHENOLIC LINING LINING C.IN C i 5 GLASS LINING ® 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION u 1 POLYETHYLENE WRAP ❑ 2 COATING r; 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION r 5 CATHODIC PROTECTION (❑ 91 NONE 45 UNKNOWN ❑ 99 OTHER E-SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNK14OWN A U 99 OTHER C. MATERIAL AND A U t BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION AU 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION M 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TGHTNESS TESTING I RgNRCKiING 11L99 OTHER V.TANK LEAK DETECTION i VISUAL CHECK u 2 INVENTORY RECONCILIATION ❑ 3 VAD02E MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 8 TANK TESTING ❑ 7 INTERSTITIAL.MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAYMR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO SUBSTANCE REMAINING GALLONS I INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPL�ANTS NAME }� S /'� DATE L. LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS M OR/CHE FOUR NUMBERS BELOW COUNTY 9 JURISDICTION N6 FACILITY A TANK x STATE LD.# PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE /Z THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH(f OCAL AGENCY IMPLEMENTING THE UNDERGROUND ST •E TANK REGULATIONS FORM B (72.91) FORD034