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ip SPATE OF CALIPoRNASTATE WATER RESOURCES CONTgOLBOARDUNDERGROUTID STORAGE TANK PERMIT APPLICATION • FORM BCOMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ I NEW PERMIT ❑ O RENEWAL PERMIT 5 CHANGE OF O ❑ 7 PERMANENTLY CLOW R-OIPbITE ONE REM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT B TE K UREB TANK REMOVED ' ..�� L DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L! '-%' S ! j ,n L S -rij- J I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.9 8. MANUFACTUR D BY: C. DATE INSTALLED(MOIDAYIYEAR) GTGI D. TANK CAPACITY IN GALLONS:i L41--,b ILTANKCONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. / Cto REGULAR �/ pGASL _7p. t MOTOR VEHICLE FUEL ❑ A OIL B. / . ❑ UNLEADED EL ❑ e AVIATION GAS 2 PETROLEUM ❑ 90 EMPTY t PRODUCT EDIb PREMIUMUNLEADE5 JETFUEL ❑ 7 METHANOL 7 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 8 99 OTHER (DESCRIBE IN ITEM D.BELOW) 0. 'F(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.A Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES 0.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF 1❑j+^ DOUBLE WALL ❑I 0 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM llu t T SINGLE WALL ❑ A SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK F7I BARE STEEL ❑ 2 STAINLESS STEEL F77 FIBERGLASS C:] A STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL 5 CONCRETE ❑ 5 POLYVNYL CHLORIDE ❑ 7 ALUMINUM ❑ 9 100% METHANOL COMPATIBLE WIFRP (Primuy TARk) 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ O EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR uNINc �j �"I 5 GLASS LINING ❑ 0 UNLINED r7 UNKNOWN ❑ 99 OTHER EMS 1S LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ D.CORgOSIOt ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ O VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECllQW ❑ 5 CATHODIC PROTECTION❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV.PIPING INFORMATION CIRCLE A IFASCVEGROUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE AC SYSTEMTYPE A U I SUCTION A U 2 PRESSURE A U O GRAVITY A U 99 OTHER A 1� B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 9S UNKNOWN A U 99 OTHER \1\V C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 0 POLYVINYL CHLORIDE(PVC)A U • FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL VO COATING A U B 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHOOICPROTECTKON A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ I AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESSTESTING ❑ O MoTNRORNG ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 7 VAPOR MONITORING❑ d AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING r 5 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 90 OTHER VI,TANK CLOSURE INFORMATION t.ESTIMATED DATE LAST USED(MOIDAY/YR) 2.ESTIMATED DUANTITY OF O.WAS TANK FILLED WITH YES F7 NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE (PRIMED&SIG AA AElL �y LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW // w�J COUNTY X JURISDICTION O7 FACILITY P TANK N / STATE I.D.# �'1 c, � �` y (� I A �, + r �! PERMITNUMBER r7 / PERMIT APPROVED 8Y/GATE - PERMIT EXPIRATION DATE 1 � FORM S (9.90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR MHK 1 '�