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tJL/ 1 E� 1JJJ 1'r,1L J1L��+J1 i VL I"IT UIZ) STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Bim. COMPILM A SEPARATE FORM FOR EACH TANK SYSTEM, MARK ONLY ❑ 1 NEW PERMFTa RENEWAL PERMi"f ❑ 5 CHANGE OF INFORMATION © 7 PERMANENTLY CLOSED ON SITE ONE �M F72 INTERIM PERMIT AMENDED PERMIT 0 TEMPORARY TANK CLCSURE ❑ B TANK REMOVED DDA OR FACILITY NAME WHERE TANK IS INSTALLED; V kA Ap10-71 I. TANK DESCRIPTION COMPLETE ALL TEM9- SPECIFY IF UNKNOWN A. OWNERS TANK f.D.0 B, MANUFACTURED BY: C. DATE INSTALLED(MOIDAYIYEAR) 01121 0 D. TANK CAPACITY IN fIIALLONS; cco Ii.TANK CONT'ENT'S IFA-1 IS MARKED, OMPLETE ITEM c, 1 MOTOR VEHICLE FUEL 4 OIL B, G REG"REGUNLEADED ❑ 9 DIESEL ❑ a AVIATION OAS 2 PETROLEUM BD EMPTY ❑ 1 PRODUCT ❑ la MIDGPADUM UM_EADED ❑ A JET FUEL 7 ME'T'HANOL ❑ iC 1[I4GRADE UMfA4E4 5 JET FUEL � a Mas 3 CHEMICAL PRODUCT � 95 UNKNOWN �WAS ❑ 2 LEADED ❑ 09 OTHER(DESCRIBE IN fTEM D,9EL0Wj 0. IF(A-1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED I C.k S.R III. TANK CONSTRUCTION MARK ONE IYe1A ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES tN Box D AND E A. TYPE OF 1 DOUBLE WALL ❑ a SINGLE WALL WITH EXTERIOR UNEFL � 5 INTERNAL BLADDER SYSTEM ❑ 98 UNKNOWN SYSTEM a SINGLE WALL ❑ A SINGLE WALL IN A VAULT ❑ 99 OTKFR S. TANK ❑ 1 BARE STEEL ❑ 2 TrAINLESS STEEL I 3 FIBERGLASS A STEEL CLAD W!FIB ERGLASS AEINF©RCED PLASTIC MATERIAL ❑ 8 CONCRETE 8 POLYVINYL CHLORIDE ❑' 7 ALUMINUM ❑ a 10Q% METHANOL COMPATIBLE W/FRP (P411wy Tisk) ❑ 7 BRONZE 10 GALVANIZEO STEEL a5 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ l PHENOUC LINING LINING OR ❑ 5 CLAGS UMNG 5�a a 11N1 NED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOLI YES— NO— D,EMRIOA ❑ I POLYETHYLENE WRAP E] 2 COAnNG 3 VINYL WW rq;71 Y FIBERGLASS REINFORCE[) PLASTIC CORROSION PROTECTION ❑ 5 GATHCOIC PROTECTION ED91 NONE 095 UNKNOWN 90 OTHER SPILL AND OVERFILL,etc. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION ECUiPMENT INSTALLED{YEAR} PROP TUBE YES NO STRIKER PLATE YES NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION GiRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE Ag 3 GRAVITY A U A FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE W/LL.L An 2 DOUBLE WALL A U a LINED TRENCH A U 06 UNKNOWN A U 29 OTHER C, MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYMNYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 6 ALUMINUM A U a CONCRETE A U 7 STEEL WI COATING A U 9 104% METHANOL GOMPATIBLE WIFRF PROTECTION A U 9 GALVANIZED STEEL A U 1D CATHCDLC PROTECTION A U 95 UNKNOWN A U 99 OTHER YfGIWGL LK LEUS 2 lllE T16lfiKE59 3 CORTwou,xtE"wn. A f1ECT11araG Llrs 5 AUTOMArC MW D. LEAK DETECTION E:]' DF;i><crm TernRa ❑ uoKtaaa+o ❑ aim ❑ wkntom 99 4T7 ER V.TANK LEAK DETECTION F-1 1 VISUAL CHECK ❑ 2 MANUAL INVENTORY 3 VADOZE A AUTCMATIC TANK ❑ 5 GROUND WATER O 6 ANNUAL TANK RECONCILIATION MONITORING GAUGING MONITORING TEsTINC3 7 CONTINUOUS INTERSTITIAL a SIR E::] 4 WEEKLY MANUAL 10 MONTHLY TANK ❑ 95 UNKNOWN ❑ 99 OTHER MONITORIND TANK A 61 TESTING VI.TANK CLOSURE INFORMATION(PeRMANENT CLOSURE IN-PLACE) 1.ESTIMATED DATE LAST USED(MOIIJAYNR) 2.ESTIMATED CUANTITY OF 3.WAS TANK FILLED WITH YES NO SUBSTANCE REMAINING GALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND To 7NE BEST OF MY KNOWLEDGE, IS TRUC AND CORREC7 TANK OWNFTS NAME DATE — fPRWM a&W4ATURL) LOCAL AGENCY USE ONLY THE STATE I.D.HUUBES IS COMPOSED OF THE FOUR NUM13M BELOW COUNTY Y JURISDICTION ff FACILITY 0 TANK 0 STATE I.D.4 PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMff APPUCATION•FORM A,UNLESS A CURRENT FORM A HAS DEEM FILED. FORM C MUST BE COMPLETED FOR INSTALLATIONS. THIS FORM SHOULD BE ACCOMPANIED RY A PLOT ALAN. FILE THIS FORM WITH TH@ LOCAL AGENCY IMPLEMENTING THE UNDERGAOUND STORAGE TANTE(REGULATIONS FORM 8 (5-m