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STATE OF CALIFDIIMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM D <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEK <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PE .. <br /> RMIT g CHAWA OF IWORMATION p 7 PERMANENTLY'c1C3;;1 <br /> ONE ITEM � INTERIM PLAMIT 4 AMENOED PERMIT 41 TEMPORARY TANK CLOSURE p A TANK REMOVV <br /> DBA ON FACILITY NAME WHERE TANK 3INSTALLED: <br /> L TANK DESCRIPTION COMPLETE A_'_rus-SPECIFY IF UNKNOWN <br /> A.OWNFITS TANK L M AL141/0 0. MANUFACTURED BY: Vx-Y's,�y.��y <br /> C.DATE MTAUM(MOD,AYNEAM I R R 4 M TANK CAPACITY IN GAL LO f`N& 1�,� - <br /> ILTANKCONTENTS EA.1ISfA"r VP—=TEITEMC. <br /> A. 5;2r1 moTOR VEHICLE FUEL A OILC• p ~a REGULAR 8 3 DIESEL <br /> B. UN„EAOEO c 4►'.S ION G113 <br /> 2 PETROLEUM 67 EMPTY 1 PpODUCT th PREMIUM 4 CyASANO4 r -�''� +NUL <br /> UNLEADED 5 JET FUEL <br /> Q 3 CHEMK:ALPRODUCT 45 UNKNOWN © 2 WASTE 2 LEADED pN OTHER (bISCRIort '% -frI D.BELOW) <br /> D. F L141)IS NOT MARKED.ENTER NAME OF a:FdSTA%GE STORED3- <br /> 111. TANK CONSTRUCTION MARK CNE 1T E V ONLY 1N&OXES A,B.AND C.AND ALL THAT APPLIES INBOX D AND E <br /> A. TYPE OF DOUBLE WALL 9 SINGLE WALL WITH EXTERIOR LINER d 95 UNKNOWN <br /> SYSTEM � 2 5WGLE WALL 4 SECONDARY CONTAINMENT IVAULTEDumq Q 9P OTKIR <br /> B. TANK E:j i BARE STEEL 2 STAIN4984 STEEL p 3 FOE14GLASS ®' 4 SI SELCLAO WIFIBERMASSREI.—ingCEDPLASTIC <br /> makRia C] 5 CONCWTE M r POLYVINYL GHLIMM p 7 ALUMINUM B JW% MEIHAWX CuWAToLE►Vt+° <br /> (Pd-gT,Ak) p 9 BP1ONm 10 GALVANIZED STEEL [j N UNKNOWN p 99 OTHER <br /> F-1 1 RUNWR LINED LK ALKYD LINING 0 a EPDXY LINING 4 PNOLIC LNINQ <br /> C.IHTL:R)DA 0 5 �g LINING <br /> LINING U .r 's tINL1NFD p ss ulawowN p 99 TITHER <br /> IS LINING MATEMML COMPATIBLE WITH=%METKAMX? YES4 ND_ <br /> D.CORROSM 0 i POLYETHYLEUE Ww 9 COATM p a VKn WRAP 5R'4 FMERaASS A4INFOACED PLASTIC <br /> PROTECTION Q 5 CATHCDIOPROTECTIDN 91 NONE 015 UNKNOWN Q 09 07NEN <br /> P,,,SPUANDOYEHFLL 3PILLCONTAINMENTPMTALLED&Ulq OY6RFkLPREVENTIONEQUIPMENTNSSALLEb(YEAM <br /> IN.F'V%G INFORMATION CIRCLE A 1FABOVEGROUND OR U KF UN ERaROUNMBOTHIFAFpUepBLE <br /> A. SYSTEM TYPE A U 1 SUCTION A 2 PRt.LUSLIAE A U 9 (MAVI TY A U 02 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE 1VALL A 2 DOL"WALL A U a LNW TSI A U 95 LOMOWN A U " 9THER <br /> Q MATERIAL AND A U 1 BARE ETWL A U & STAINLISS STE3, A V a POLYVINYL CHLORIN LP11C}A4 FIBERGLASS PIPE <br /> CORROSION A U 5 AILmJNLN A U s PONCREIE A U 7 STEELVOCOA.TNO A i loos METHANOL COMPATMLEUFRP <br /> PROTE07M A U 0 CALVAN=STEEL A U 10 CATHODICPROTECTION A U N UNKNOWN Ali so OTHER <br /> D. LEAK DETECTK#N [3 1 E]MA -— <br /> V.TANK LEAK DETECTION <br /> 0 1 VUIUAL CHECK 0 2 wvrLpmRY itmx=UATION O a YAo=Atcomam0 4 ALROMATc TANK GALMM p 5 GROUND rAWA NcNrTORma <br /> Q 4 TANk TESTING 7L i N UPILITITIIL MONIMFLINO 91 NONE 1� W UlMK O%W p pN QTI Ep <br /> VL TANK CLOSURE INFORMA71ON <br /> 1.0TRAMMD DATE LAST Umm IMOIDAYATTq A WTIMATID OLM01 Y OF a.WA$TANK FILLED wm <br /> SUBSTANCE RELVAN1NG PAILLOND FEAT MATERIAL T YES L_J <br /> THIS POW HAS BEEN COWLET801 IA DEA P&M LTY 0F?ERJU TO.W SEST GIF UY XI07 EDGE IS TRUEAND CORRECT <br /> APPLICANT'S NAME DATL <br /> r/wm s r1c1Nn41RE1Ls /,Zr--�- .. A —I%r <br /> LOCAL AGENCY USE ONLY THE STATE IA NUMBER M OOMPDSED OF THE FOUR WAVERS BELOW <br /> COUNTY S, .NJalLILNG'CION f FAMrrf f . TAWS <br /> STATE I.o. m = 71 1 17 W16A I 1 1 . 1 1 <br /> PfRMRN41Vim POVITAPPROVE®OV DATE FfFIM'r EXPIRATION DATE <br /> T14S POO M MUST BE A wWAWD BY A PLRW APPUCATION-FORM A,UW-NS A CUR Mff FORM A RAS BEEN FiLEO. <br /> FORM Q 112-1;11 FILE THIS FORM wml THEW AGENCY IMPLEME'N'TING THE UNDERGROUND STORA REGUTA71ONS� ��b q�/, fCtapp3tB.R6 <br /> LOO/600 'III 'I'IRHS OST99L90TS XVd 9T=TT ` ✓96 9T/T0 <br />