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• • ♦eso.0. ea co STATE OF CALIFORNIA 4? STATE WATER RESOURCES CONTROL BOARD w a- .. u o° =ms. 1 -o UNDERGROUND STORAGE TANK PERMIT PPLICATION - FORM �` COMPLETE A SEPARATE FORM FOR CH TANK SYSTEM. MIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE) OWE 3 RENEWAL PER ❑ B TANK REMOVED 1 NEW PERMIT /j✓7 MARK ONLY O ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ONE ITEM 2 INTERIM PERMIT e L DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN S. MANUFACTURED BY: A. OWNER'S TANK I.D.# D D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MO/DAVNEAR) ILTANKCONTENTS IFA-11SMARKED.COMPLETE ITEM C. ❑ 1,REGULAR ❑ 3 DIESEL ❑ 6 AVIATIONGAS A. ❑ 1 MOTOR VEHICLE FUEL ❑ 4 OIL B. C UNLEADED ❑ 4 G,p3AHOL ❑ 7 METHANOL ❑ BD EMPTY ❑ 1 PRODUCT ❑ 1bUNL AID D UM ❑ 5 JET FUEL ❑ 2 PETROLEUM 2 WASTE ❑ 2 LADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) ❑ 3 CHEMICALPRODUCT L-195 UNKNOWN E] C.A.S.%: D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.AND Cl AND ALL THAT APPLIES IN BOX D AND 95 UNKNOWN [:] 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER 9 A. TYPE OF ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 9 OTHER SYSTEM ❑ 2 SINGLE WALL ❑ ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC 1 BARE STEEL 6 POLYVINYL CHLORIDE 7 ALUMINUM S. TANK ❑ B 100x METHANOL COMPATIBLEW/FRP ❑ 5 CONCRETE ❑ ❑ MATERIAL E] 95 UNKNOWN ❑ 98 OTHER (PrimaryTenk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 1DOx METHANOL? VES ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING E] 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC D.CORROSION ❑95 UNKNOWN ❑ 99 OTHER PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE OVERFILL PREVENTION EQUIPMENT INSTALLED(NEAR) E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE AIFABOVE GROUND ORUIFUNDERGROUND,BOTGRAVITyIF APPLICABLE A U OTHER A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE 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 ? SEE IW/'CO TING DE(PVC)AA U 9 FIBERGLASS00% METHANOL COMPATIBLE W/FRP 5 ALUMINUM A U 6 CONCRETE A U CORROSION A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER-� PROTECTION A U 9 GALVANIZED STEEL A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TE STING ❑ 9 MONITORING ❑ V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ e TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ et NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES ❑ NO❑ 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2ESTIMATED SUBSTANCE OUANTII TY O OF GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED GE, E IS TRUE AND CORRECT APPLICANTS NAME (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY T TATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNT # JURISDICTION# FACILITY# STATE LD.# PERMIT EXPIRATION DATE PERMIT NUMBER ERMIT APPROVED BY/DATE r' FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR001-R5 0 0 /4