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(� 5TATE OF CALIFORNA • �/�� ^``,. °jc STATE WATER RESOURCES CONTROL BOARD ^ .�'�`t UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM COMPLETE A SEPARATE FORM FOR5ACH TANK SYSTEM `•��• i—� MARK ONLY ❑ 1 NEW PERMIT ❑ 0 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTL�V CLOS'0 ITE ONE ITEM 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ^ 8 TANK REM is ij ED )`.( DBA OR FACILITY NAME WHERE TANK IS INSTALLED: --702 (i[ G I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK LO.A8. MANUFACTURED BY: C. DATE INSTALLED(MO/DAY/YEAR) D. TANK /CAPACITY IN GALLONS/ 1 II.TANK CONTENTS IFA-1 IS MARKED.COMPLETE ITEM C. A. 1 MOTOR VEHICLE FUEL ❑ A OIL B. C. 12UNLEAO R O DIESEL ❑ B AVIATION GAS 2 PETROLEUM W EMPTY / PgOOUCT ❑ PRE IU A GASAHOL ❑ 7 METHANOL ❑ 0 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEAOEDD 5 JETFUEL 99 OTHER (DESCRIBE IN ITEM 0. BELOW( D. IF(A.I)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.i III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLIES IN BOX A. TYPE OF ❑ 1 DOUBLE WALL 0 SINGLE WALL WITH EXTERIOR LINER 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL A SECONDARY CONTAINMENT (VAULTED TANK) 99 OTHER S. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ O FIBERGLASS ❑ s STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE 7 ALUMINUM ❑ B 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE IO GALVANIZED STEEL 95 UNKNOWN ❑ 99 OTHER ❑ I RUBBER LINED ❑ 2 ALKYO LINING ❑ O EPDXY LINING ❑ A PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED LINING ❑ 9s UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO_ 0.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ S VINYL WRAP ❑ A FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER IV. PIPING INFORMATION CIRCLE A IFABOVEGRQUNDOR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U I SUCTION A U 2 PRESSURE A U 9 GRAVITY A U 99 OTHER S. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE WALL A U S LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U O POLYVINYL CHLORIDE(PVC)A U A FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 5 CONCRETE A U 7 STEEL WI COATING A U 9 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 0. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING ❑ 0 W S L ❑ 9g OTHER MONBORING V.TANK LEAK DETECTION ❑ I VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ O VAPOR MONITORING❑ A AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE C:] 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF O.WAS TANK FILLED WITH SUBSTANCE REMAINING GALLONS INERTMATERIAL? YES ❑ NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT APPLICANTS NAME DATE / ry ^ LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHE FOUR NUMBERS BELOW nU�J L wJ STATE LD. COUNTY 0 JURISDICTION# FACILITY# TANK# U l PERMIT NUMBER / PERMIT APPROVED BYNATE PERMIT EXPIR FIONOATE 't� FORM B (9.9a) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORW7tbM