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0 -40 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD '� s UNDERGROUND STORAGE TANK PERMIT APPLICATION - F09M �. COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MARK ONLY/ NEW PERMIT ❑ 3 RENEWAL PERMIT F75 CHANGE OF INFORMATION ❑ 7 PERMA TLY CLOSED ON $I ONE ITEM �/2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK R MOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: Q k % AX�7 L TANK DESCRIPTION COMPLETE ALL ITEMS — SPECIFY IF UNKNOWN I A. OWNER'S TANK 1. D. # B. B. MANUFACTURED BY: © C C. DATE INSTALLED(MO/DAY/YEAR) ❑ ib PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET L D. TANK CAPACITY IN GALLONS: 2 WASTE II TANKPONTFNTS IP e_1 Le MaGKGn cnMPKPTF ITFYC A ❑ 1 MOTOR VEHICLE FUEL lef4 OIL B. to REGULAR 3 DIESEL C. ❑ UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 'PHDUCT ❑ ib PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED ❑ 5 JET L ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN 2 WASTE ❑ 2 LEADED 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 ALLTHAT APPLIES IN BOX D A. TYPE OF E�rrl DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM F72 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (V LTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL Ek3 FIBERGLASS ❑ 4 STEEL CLAD W/ FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER . 6 CONCRETE A U ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINyJ(iJ 4 �"� ININC C. INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN\\\�\. A— LINING ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTI IAL 99 OTHER [:]NITORING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES _ NO D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND—BOTH IFAPPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE p GRAVITY A U 99 OTHER 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 C. MATERIAL AND A U 1 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 6 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 A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 INTERSTI IAL 99 OTHER [:]NITORING MO V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN ❑ 99 OTHER THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE ��f (PRINTED a SIGNATURE) / __j LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # AGILITY # TANK 1� STATE LD.# ?� ❑ru❑1-1 PERMIT NUMBER PERMIT APPROVED BY/DAT / V !� P IT EXPIRATION DATE FORMS (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION " FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. MR0034844