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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i /J1INDERGROUND STORAGE TANK PERMIT APPLICATIONOAF' RMB ae y COMPLETE A SEPARATE FORM FOR EAC TANK SYSTEM. MARK ONLY F71 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF FORMATIONVrIPERMANENTLY CLOS ITE ONE REM F72 INTERIM PERMIT F-] OSURE 4 AMENDED PERMIT ❑ 8 TEMPORAR TANK CLa TANK REMOVED I -X DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 2 9,J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNERS TANK I.D.s B. MANUFACTUR BY: C. DATE INSTALLS O/DAY/YEAR) D. TANK CAPACITY GALLONS: II.TANKC ENTS IFA-11SMARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1aUNLEAD R 3 DIESEL ❑ 9 AVIATION GAS ❑ 2 PETROLEUM ❑ 00 EMPTY 1 PRODUCT ❑ 1b PREMIUM LJ 4 GpSAHOL ❑ 7 METH 1 ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 UNLEADED 5 NE THERL(DE SLOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S. III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLIES IN BOX DANDE A. TYPE OF ❑ I/ItOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK i BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS O 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ e POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTmk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 8 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VI WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION [-] 5 CATHODIC PROTECTION E:] 91 NONE UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT 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 U 2 PRESSURE A U 3 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 RARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U S CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODICPROTECTKNN A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ 3 MONITORING ❑ 99 OTHER / V.TANK LEAK DETECTION �\N ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING N ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATEDQUANTITY OF 3.WAS TANK YES NO❑ SUBSTANCE REMAINING GALLONS INE RT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND O THE BEST OF MY KNOWLEDGE, IS TRUE AN REC APPLICANTS NAME DATE (PRINiEDb SIGNAIDREI V/1__ (X//L� �/�\ LOCAL AGENC2 USE ONLY THE STATE I.D.NUMBER S COMPOSED OF HE FOUR NUMBERS BELOW 1 TATE I.D.# Im C x JURISDI TIO A LffV x TANK x PERMITNUMBER PERMIT APPROVED BY ATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM SS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH T�LOCAL AGENCY IMPLEMENTING THE UNDERGROUN P-52.E_7ANK REGULATIONS FORME (12-91) \S (% (/ / /}/�� f FOIIOf096R6