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>i STATE OFCAUFORNIASTATE WATER RESOURCES _ OL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMS COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM, ' m . MARK ONLY ED NEW PERMIT 133 RENEWAL PERMIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 7 PERMANENTLY CLOSED ONSITE ORA OR FACILITY NAME WHERE TANK IS INSTALLED: �+ ® B TANK REMOVED I. TANK DESCRIPTION COMPLETE ALLI7EMS_ SPECIFY IFuoh. wN 'r 7A. OWNER'S TANK I.D.a u —JIT! BY: C. DATE INSTALI.ED(MO/DAY/YEAR) 0. TANK CAPACITY IN GALLONS S�Y� II.TANK CONTENTS IFA•113MARKED.COMPLETE ITEM C. V A ❑ 1 MOTOR V::F=E:STORE07t,,214 IL B. O, 3 DIESEL ❑ e AVIATION CAB❑ 2PETROLEUMPTY ❑ 1 PRODUCT la PREMUM UNLEACED a GASANOL ❑ 7 METHANOL❑ 3 CHEMICAL NKNOWN Iii 2 )VAS to NDOpApE UREAOEDB JET EUEL ❑ B4Lt1 ( ESCNBE RI REV O.BHDW)0. IF(A I)IS NO MMARKE SiOREO /Y� M/ V•G GAS.a: III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A 9,AND C.AND ALL THAT APPLIES IN BOX 0 AND E A. TYPE OF ❑ i DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 9'ITEflNAL BLADDER SYSTEM ❑ SYSTEM 2 SINGLE WALL ❑ t SINGLE WALL IN A VAULT ❑ 99 OTHER 95 UABOJOWN B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ d STEEL CUD W/Fl8ERGLASS REINFORCED pLASTIC MATERIAL 5 CONCRETE ❑ B POLYVINYL CHLORIDE ❑ ? ALUMINUM ❑ B 100% METHANOL COMPATIBLE wiFnp (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER � C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING T-r� ❑ 3 EPDXY LINING ❑ 6 PHENOLIC LINING LINING OR ❑ 5 GLASS LINING ' y` 8 UNUNE13 ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO_ A� D.EXTERIOR ❑ I POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ d FIBERGLASS REINFORCED PLASTIC CORROSION PROTECTION ❑ 5 CATHODIC PROTECTION ® 91 NONE ❑95 UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,etc. SPILLCONTAINMENT INSTALLED(YEARINSTALLED—(YEAR) ) OVERFILL PREVENTION EQUIPMENT 1.r 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 U t SUC770N A U 2 PRESSURE A r3 GRAVITY A U d FLEXIBLE PIPING A U 99 OTHER r 8, CONSTRUCTION A t SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A(D 1 WE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U d FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP r PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHQOICPROTECTION A U 95 UNIWOWN A U 99 OTHER D. LEAK DETECTION ❑t aETcu la,\IEAII C:]z h TwxtK9ss ❑3mx�au vaDumul ❑d Btcl�c unc ❑s AIJT()�wln�c rw Q yy oTMm_4��_. V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 RECONCILIATIONMONITORING ❑ 3 ❑ d GAUGING TANK ❑ 5 GROUND MONITORING ANNUALTANK MANUAL ❑B TESTING ❑ 7 COMINUOU INTERSTITIAL ❑ S SIR ❑ 9 TANK GA GINUAL❑ 10 MONTHLY TANK ❑ 95 UNKNOWN ❑99 OTHEMTORR TESTING VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) r 1.ESTIMPTTED PATE LAST USED(MO/OAWYP) 2.ESTIMATED QUANTITY OF3 WAS TANK FILLED WITH ,/ES SUBSTANCE REMAINING GALLONS INERT MATERIAL7 I� NO-91 THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE;IS TRUEANO CORRECT r TANK OWNERS NAME ! _ Lu DATE (PRWT131\SK:ruILRQ Ja& (u -� �r .IZ_�-rte LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW - COUNTY A JUFIISOICTON a �--F�A-C-ILI��TY�a -� TANK K (-- STATE I.DJ m = I I � 1 --�� PERMIT NUMBER PFANOT APPROVED BYIOATE PERMLT EXPIRATION DATE' THIS FORM MUST BE ACCOMPANIED BY A PERYRAPPUCATION-FORM A UNLESS A CURRENT FORMA HAS SEEN FILM FORM C MUST BE COMPLETED FOR INSTALLATIONS.THIS FORM SHOULD SE ACCOMPANIED BY A PLOT"`N. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THF"NOERGROUND STORAGE TANK REGULATIONS _ FORM 8 (695) *1 ��