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ooa ey ^e A.,�iu epYi STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATIO • FOR 1�J eOPN.� /� COMPLETE A SEPARATE FORM FOR EACH TANK SYST l.� 5 CHANGE OF INF MATION ❑ 7 PERMANENTLY CLO D ON E 1 NEW PERMIT ❑ 3 RENEWAL PERMIT MARK ONLY O ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK C URE ❑ 6 TANK REMOVED ONE ITEM 2 INTERIM PERMIT DBA OR FACILITY NAME WHERE TANK IS INSTALLED: a I. TANK DESCRIPTION COMPLETE ALL ITEMS"- SPECIFY IF UNKNOWN B MANUFACTURED BY: A. OWNER'S TANK I.D.k 3y �D /J D. TANK CAPACITY IN GALLONS: Q�l.r C. DATE INSTALLED(MOIDAYIYEAK) ILTANKCONTENTS IFA-11S MARKED,COMP ITEM C. to REGULAR n 3 DIESEL E] 6 AVIATIONGAS ❑ 1 MOTOR VEHICLE FUEL 4 OIL B. C. ❑ UNLEADED L�J-I 4 GASAHOL 7 METHANOL A' ❑ 80 EMPTY ❑ 1 PRO UCT ❑ 1bUNLEADED ❑ 5 JET FUEL ❑ ❑ 2 PETROLEUM 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN WASTE ❑ 2 LEADED F799 OTHER (DESCRIBE IN ITEM D. BELOW) C.A.S.%: O D. IF IA.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES AB.AND C.AND ALL THAT APPLIES IN BOX ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN A. TYPE OF 99 OTHER ❑ SYSTEM SINGLE WALL 4 SECONDARY CONTAINMENT (VAULTED TANI() 1 BARE STEEL ❑ 2 STAINLESS STEEL E] 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B TANK ❑ 8 100% METHANOL COMPATIBLE W/FRP MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM (Pl AT TAnk) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER F-1❑ 5 GLASS LINING 1:1 1 RUBBER LINED 2 AL D LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— N ❑ ❑ L WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC POLYETHYLENE WRAP 2 COATING 3 VINY D.CORROSION ❑ 1 ❑ gg OTHER PROTECTION F-15 CATHODIC PROTECTION ❑ 91 NONE 95 UNKNOWN ❑ IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTH IFAPPLICABLEY�GR p U 99 OTHER A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE p B. CONSTRUCTION A 1 SINGLE WALL p U 2 DOUBLE WALL A U 3 LINED TRENCH p U 95 UNKNOWN A U 99 OTHER A BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE C. MATERIAL AND A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL WI COATING A U 8 100% METHANOL COMPATIBLE WIFRP CORROSIONCATHODIC PROTECTION A U 95 UNKNOWN A U 99 O ER 10 PROTECTION A U 9 GALVANIZED STEEL A U 3 IMERSTITIAL g9 OTHER 1AUTOMAI LINE LEAK DETECTOR ❑ 2 LINE TIGHTNESS TESTING ❑ MONITORING D. LEAK DETECTION ❑ -- V.TAN EAK DETECTION 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 IN MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 3.WAS TANK FILLED WITH YES `❑ NO ❑ 2.ESTIMATED QUANTITY OF GALLONS INERT MATERIAL? 1.ESTIMAT D DATE LAST USED(MOIDAVfIR) SUBSTANCE REMAINING THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT A APPLICANT'S NAME (PRINTED B SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TANK# COUNTY# JURISDICTION# FACILITY# STATE LDAJI LyylYll )'I PERMIT EXPIRATION DATE PERMI:NIl B PERMIT APPROVED BVIDATE FORM B (9-90) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR903413-114