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STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD d� _ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM e COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT ❑ K AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE B TANK REMOVED 4::� 9 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: IV, C G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNER'S TANK I.D.N / B. MANUFACTURED BY: - C. DATE INSTALLED(MO/DAYNEAR) 1 D. TANK CAPACITY IN GALLONS: Z ZQi„Jta II.TANK CONTENTS IF A-1 IS MARKED.COMPLETE Am C. A ❑ 1 MOTOR VEHICLE FUEL ❑ K OIL B. C. 1• REGUWi UNLEADED O 3 DIESEL ❑ 6 AVIATION GAS .01PETROLEUM ❑ 80 EMPTY 2r1 PRODUCT 1a PREMMM UNLEADED ❑ A JET FUEL ] METHANOL 2 ❑ Ic MOGRADE UNLEADED 5 JET FUEL B MBS ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED J,03 99 OIHER(DESCR9)E W REM D.BELOW) D. IF(AI)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED L C.A S.R: Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.S.AND C.AND ALL AT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM oF2r 2 SINGLE WALL ❑ l SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK �I BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ A STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ I RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ A PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ❑ 6 UNLINED c2r95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN ED99 OTHER E.SPILL AND OVERFILL,t1C. SPILL CONTAINMENT INSTALLED(YEAy- OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) DROP TUBE YES_ NO STRIKER PLATE YES_ NO_ DISPENSER CONTAINMENT YES_ NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A&1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U a FIBERGLASS PIPE CORROSION A 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WICOATING A U 6 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑i uEc"v"cu u+E TEAK ❑2 INE iXa A. ❑3 WNINUOJ6 NIEASHRLL ❑A ELE ,.A l94 ❑5 Au0WT10 Pur OTHER OETECiOP TESTNIO MONiORNG LME OETECT011 9HJT00'A'H V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCIUATIONINVENTORY ❑ 3 VADOZEMONITORING ❑ • GAUGING AUTOMATIC TANK ❑5 GROUND MONITORINGTER ❑6 ANNUAL TESTING ❑ 7 MONITORINGINTERSTITIAL ❑ 6 SIR ❑ 9 TANK WEEKLY MANUAL ❑10 MONTHLYTESTING TANK y�a5 UNKNOWN ❑99 OTHER VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PLACE) 'T I.ESTIMATED DAT LAST USE (MO/DAYNR) 2.ESTIMATED OUANTITY OF 3.WAS TANK FlLLED WITH YES NO❑ / SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANKOWNER'S NAME / DAT �� (PPIMEl 60NANREI `/ 1171 LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBER BELOW COUNTY t JURISDICTION N FACILITY N Oldl 0 T OD STATE I.D:# m -7 s 5 7 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMT IRATION UAT THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICAT'^N-FORM A,UNLESS A CURRENT FORMA HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD BE ACCOMPANIED BY A PLOT PLA JE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE U'- -RGROUND STORAGE TANK REGULATIONS ,,ff FORME (695) ll..� *mw 9-10- s//