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c,JVRCe� STATE OF CALIFORNIA 'w STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Bea s; t,rA o COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. c'`"On"•. MARK ONLY 7X 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVE[) DBA OR FACILITY NAME WHERE TANK IS INSTALLED: L , NTH R O ti Ev RoN G, V 1• TANK DESCRIPTION COMPLETE ALL ITEMS -- SPECIFY IF UNKNOWN A. OWNER'S TANK I. D, # .3 B. MANUFACTURED BY: C. DATE INSTALLED (MOIDAYIYEAR) Ju 1--'j en D. TANK CAPACITY IN GALLONS: ILTANKCONTENTS IFA -1 IS MARKED.COMPLETEITEM C. sU A, 1 MOTOR VEHICLE FUEL ❑ 4 OIL B, C ® 1 UNLEADED N� p ❑ 3 DIESEL ❑� 6 AVIAT4pN GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ 1 PRODUCT ❑ ib PREMIUM ❑ 4 G T FUEL ❑ 7 METHANOL UNLEADED ❑ 5 JE7FUEL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF (Al) IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C. A. S. n 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A. B. AND C. AND ALL THAT APPI IFR IN Mn-, n emn c A. TYPE OF 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1170% METHANOL COMPATIBLE WIFRP {Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C INTERIOR LINING ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES` NO_ D. CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP f�.? 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER E. SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED (YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED (YEAR) IV.. rIrRVU IIVEUIlIVIAIIVN CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND, BOTH IF APPLICABLE A. SYSTEM TYPE A(D 1 SUCTION Aff 2 PRESSURE) A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A Uo 1 SINGLE WALL WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE (PVC)A 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/ COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ INTERS I I II`� MONITORING LJ 99 OTHER V. TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING[ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUNDWATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑� 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI. TANK CLOSURE INFORMATION 1. ESTIMATED DATE LAST USED (MOIDAYJYR) 2. ESTIMATED QUANTITY OF 3. WAS TANK FILLED WITH YES ❑ NO ❑ SUBSTANCE REMAINING GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT APPLICANTS NAME (PRINTED& SIGNATURE) ,a 1n. f1 \( `� DATE r Al LOCAL AGENCY USE ONLY THE STATE I.D. NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY # JURISDICTION # FACILITY # TANK # J STATE 1045 . f 0 S d' 7o�' (o PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION DATE FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION - FORM A, UNLESS A CURRENT FORM A HAS BEEN FILED. 0 FOR0004845