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STATEOFCAUFORNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM Bq ! a COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. `,� MARK ONLY Q 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION y 7 PERMANENTLY CLOSVSIT� ONE ITEM ❑ 2 INTERIM PERMIT F-1d AMENDED PERMIT [:] e TEMPORARY TANK CLOSURE L}L_I a TANK REMOVED OBA OR FACILITY NAME WHERE TANK IS INSTALLED: 141 I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.R 'Jz S. MANUFACTURED BY: C. DATE INSTALLED(MOIDAYNEAR) 'GA-10 p. TANK CAPACITY IN GALLONS: U Q G II.TANKCONTENTS IFA-11SMARKED,COMPLETEITEMC. A. W 1 MOTOR VEHICLE FUEL ❑ 6 OIL B. C. ❑ 1a REGULAR 3 DIESEL ❑ e AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY 1 PRODUCT ❑ 1eUN ELEAOED 8 5 JGASAH L ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ % UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) 0. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED ,6 v C A.S# III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C.AND ALL THAT APPLIES IN 13OXD A. TYPE OF rI�pPl� 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ % UNKNOWN le SYSTEM 2 SINGLE WALL ❑ d SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ s STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 IOP% METHANOL COMPATIBLE WIFRP (PdmuyTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ % UNKNOWN ❑ 90 OTHER ❑ 1 RUBBER LINED ❑ 2 AUKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR 5 GLASS LINING 8 UNLINED % UNKNOWN 22 OTHER LINING ❑ ❑ ❑ LS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE _Pq95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION AU02 PRESSURE A U 3 GRAVITY A U 90 OTHER B. CONSTRUCTION A SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U % UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)GA FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 8 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLEWIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U % UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 AUTOMATIC LINE LEAK DETECTOR LINE TIGHTNESS TESTING Q 3 WERORMG Q 90 OTHER MONV.TANK LEAK DETECTION [_1 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING eTANK TESTING ❑ 7 INTERSTRIALMONMORING ❑ 91 NONE ❑ % UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LA SEO /pAY/YR) // 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING �'^ YES_GALLONS INERTMATERIAL? E] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEFYURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME \ "1 , 0 DAT �\ IP PLIC lGIGWIAME LOCAL AGENCY USE ONLY THE STATE I.D.NUMBEI IS COMPOSED 44EF R NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# STATE I.D.# Nu777 ,L Z f� PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORMA,UNLESS A CURRENT FORMA HAS BEE PILED. FORO¢N&0.a