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Sauaces r r STATE OF CALIFORNIA ` o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- 'FORM Bhil COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. ❑ 5 CHANGE OF INFORMATION ❑ a!#T 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ MARK ONLY ❑ q AMENDE3 PERMIT ❑ 6 TEFAPORARY TANK CLOSURE ONE ITEM 2 INTERIM PERMIT DBA OR FACILITY NAME INHERE TANK IS INSTALLED. 1. TANK DESCRIPTION COMPLETEAL�S SPECIFY IF UNKNOWN B MANUFACTURED BY: A. OWNER'S TANK I.D.x D. TANK CAPACITY IN GALLONS: C. DATE INSTALLED(MOIDAYNEAR) ILTANKCONTENTS IFA-1 IS MA PIKED.COMPLETE iTEM C. �y 1a REGULAR � 3 DIESEL ❑ 6 AVIATION GAS ❑ IL B. C. Y� UNLEADED 4 GASAHOL 7 METHANOL A 1 MOTOR VEHICLE FUEL 4 O1 PRODUCT 'ib PREMIUM ❑ ❑ 2 PETROLEUM ❑ 60 EMPTY 54, }� UNLEADED ❑ 5 JET FUEL ❑ ❑ 95 UNKNOWN ❑ 2 WASTE 2 LEADED ❑ 99 OTHER (DESCRIBE IN 3 CHEMICAL PRODUCT ITEM D. BEL C.A.S.#: D. IF(A.i)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III, TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX 0❑ 95 UNKNOWN ❑ 1 pOUBL WALL E] 3 SINGLE WALL WITH EXTERIOR LINER A TYPE OF ❑ 99 OTHER SYSTEM ❑ 2 SINGLE LL 4 SECONDARY CONTAINMENT (VAULTED TANK) 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD WI FIBERGLASS REINFORCED PLASTIC ❑ 1 BARE STEEL ❑ B 100% METHANOL COMPATIBLE WIFRP B. TANK Q 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM 5 CONCRETE ❑ MATERIAL ❑ ❑ 95 UNKNOWN ❑ 99 OTHER (PrimaryTank) ❑ 9 BRONZE ❑ 1D GALVANIZED STEEL ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING ❑ i RUBBER LINED ❑ 99 OTHER C.INTERIOR5 GLASS LINING 6 UNLINED E-195 UNKNOWN LINING — IS LINING MATERIAL COMPATIBLE W H 100Y METHANOL? YES_ NO�- ❑ F-1 1 POLYETHYLENE WRAP 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC ❑ D.CORROSION ONE ❑95 UNKNOWN 99 OTHER PROTECTION ❑ 91 5 CATHODIC PROTECTION ❑ E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YE ) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND 0 U IF UNDE RGROUND,BOTH IF APPLICABLE A U 1 SUCTION A U 2 PRIES RE A U 3 GRAVITY A U 99 OTHER A. SYSTEM TYPE 95 UNKNOWN A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL A U 2 DOUBLE ALL A U 3 LINED TRENCH A U C. MATERIAL AND A U 1 BARE STEEL A U 6 CONCRETE TEFL AA U 7 SS7OEELIWYIDE(PVC)A 2 STAINLESS COATINGA U 9 FIBERGLASS 00METHANOL COMPATIBLE WIFRP CORROSION A U 5 ALUMINUM A U 95 UNKNOWN A U 99 OTHER PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PRO CTITN k U ❑ g S AL 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR ❑ 2 LINE T TNESS TESTING MCNITORYNG C� V.TANK LEAK DETECTION ❑ 1 VISUAL GHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZEMONITORING ❑ 4 AUTOMATIGTANKGAUGING GROUNDWATER WATER MONITORING 99 ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE \❑ 95 UNKNOWN VI.TANK CLOSURE INFORMATION ESTIMRTEOOUANTtTY OF 3.WAS TANK FILLED WITH YES U NO 2 GALLONS INERT MATERIAL? 1 ESTI}/ ATAAST USED(MOIDAYIYR} SUBSTANCE REMAINING j- IS TRUE AND CORRECT THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDD EE APPLICANTS NAME I PRINTED&SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# FACILITY# Twl�-- —.— STATE L4.# �❑ PERMITNUMBER PERMIT APPROVED BYIDATE PE MIT EXPIRATION DATE THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS Foaolz FORM 8 (12-91) �/?0 ICJ r�q 111 `r7 Glj