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STATEOFCAUFOMAA `✓ c <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM 6 w ` <br /> � • a <br /> COMPLETE A SEPARATE FORM FOR EAC K SYSTEM a `'��o��•' <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED ONSITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT <br /> 6 TEMPORARY TANK CLOSURE O 8 TANK REMOVED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a S S 7 .T f ✓T7gC5 �Sca / <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.# B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MODAY/YEAR) D. TANK CAPACITY IN GALLONS: s� <br /> II.TANK C ENTS IFA-1 IS MARKED,COMPLETE ITEM C. <br /> A. UNLEADE1 MOTOR VEHICLE FUEL 4 OIL 9, C. EGUDED n 3 DIESEL O 6 AVIATIONGAS <br /> D 2 PETROLEUM O 9EMPTY 1 PRODUCT O 10IH 4 GASAHOL <br /> UNLEADED O 5 JETFUEL 7 METHANOL <br /> D <br /> O 3 CHEMICAL PRODUCT 956 UNKNOWN O 2 WASTE O 2 LEADED O 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.R: <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B.AND C.AND ALL THAT APPLIES IN BOXD <br /> A. TYPE OF 1 LISLE WALL 3 SINGLE WALL WITH EXTERIOR LINERI n VIII UNKNOWN <br /> SYSTEM GLE WALL 4 SECONDARY CONTAINMENT (VAULTEDTANK) E�] 99 OTHER <br /> B. TANK BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS E:l 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL 5 CONCRETE D 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP <br /> (Pdm3ryTenk) 7 B BRONZE �O 11,0•O,.A�LVANI2ED STEEL �5 UNKNOWN O 99 OTHER <br /> 1 RUBBER LINED I�}�q/�-^.D LINING ZIAXV LINING O 4 PHENOLIC LINING <br /> C.INTERIOR 5 GLASS LINING '\I�(NITT/88 NLINED 95 UNKNOWN O 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE H METHANOL? YES_ NO— <br /> D.CORROSION 1 POLYETHYLENE WRAP 2 COATING O 3 VINYL WRAP 4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION 0 91 NONE 0 95 UNKNOWN 0 99 OTHER <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE iU 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION AM 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 6 100% "NOL COMPATIBLE W/FRP <br /> PROTECTION AC9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 O <br /> D. LEAK DETECTION Q 1 AUTOMATIC LINE LEA-DETECTOR O 2 LINE TIGHTNESS TESTING 7 MMONR 11I AL 9 OTHER <br /> V.TANK LEAK DETECTION <br /> ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION E 3 VAPOR MONITORING O TOMATIC TANK GAUGING O 5 GROUND WATER MONITORING <br /> 6 TANK TESTING 7 INTERSTITIAL MONITORING ❑ B1 NONE 95 UNKNOWN 099 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DA})AST USED(MO/DAV/VR) 2.ESTIMATED QUANTITY OF ',nn 3.WAS TANK FILLED WITH YES NOEel <br /> SUBSTANCE REMAINING OO GALLONS INERTMATERIAL7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANTS NAME DATE <br /> (P W NTED 8 SIGNRNHEI <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW <br /> STATE I=D# COUNTY# JURISDICTION# FACILITY# TANK# <br /> STATE LD.# L KrPNi <br /> PERMIT NUMB PERMIT V �V E MIT EXPIRATION DATE <br /> FORM B (990) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FOn00119-Fi <br /> 1 <br />