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0 'cboun ee o <br /> •u,. y9 <br /> STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FOR 'Zt(oIi <br /> ��� COMPLETE A SEPARATE FORM FOR EACH TANK SYSTE 01 <br /> 12— <br /> C.• ❑ 5 CHANGE OF INFOR ❑ 7 PERMANENTLY CL ED SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> MARK ONLY O ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE ❑ 8 TANK REMOVED <br /> ONE ITEM 2 INTERIM PERMIT <br /> ce <br /> DBA OR FACILITY NAMEE WHERE TANK IS INSTALLED: <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS– SPECIFY IF UNKNOWN S. MANUFACTURED BY: <br /> A. OWNERS TANK I.D.% C`� <br /> 0. TANK CAPACITY IN GALLONS: <br /> C. DATE INSTALLED(MOIDAV/VEAR) <br /> ILTANKCONTENTS IFA-11S MARKED,COMP ITEM C. aREGULAR ❑ 3 DIESEL ❑ 6 AVIATION GAS <br /> O. ❑ UNLEADED ❑ 4 GASAHOL <br /> A ❑ i MOTOR VEHICLE FUEL 4 OIL B. ❑ 7 METHANOL <br /> ❑ BO EMPTY ❑� ' ,PRODUCT ❑ 1bUN EAPRE ID D ❑ 5 JETFUEL <br /> ❑ 2 PETROLEUM L^".�ypSTE p LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> ❑ 3 CHEMICALPRODUCT ❑ 95 UNKNOWN ❑ ❑ <br /> c.A.s.%: p <br /> D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED <br /> III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B,AND C,AND ALL THAT APPLIES IN BOX <br /> ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN <br /> ❑ 1 DOUBLE WALL 99 OTHER <br /> A. TYPE OF �—I � ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ <br /> SYSTEM I rY2 3iNGLE WALL <br /> 'WV BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD Wf FIBERGLASS REINFORCED PLASTIC <br /> B TANK ❑ B 100% METHANOL COMPATIBLE W/FRP <br /> 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM <br /> MATERIAL ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER <br /> (Primary Tank) ❑ 9 BRONZE ❑ <br /> ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING <br /> ❑ 1 RUBBER LINED ❑ 99 OTHER <br /> C.INTERIOR ❑9. UNLINED ❑ 95 UNKNOWN <br /> ❑ 5 GLASS LINING <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? VES_ — <br /> ❑ 2 COATING ❑ 3 VINYL WRAP 4�FIBERGLASS REINFORCED PLA <br /> DSTIC <br /> D.CORROSION ❑ 1 POLYETHYLENE WRAP 99 OTHER������ ^' - <br /> PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE <br /> ❑95 UNKNOWN <br /> IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND.BOTHIIFAAVPP APPLICABLE A U 99 OTHER <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A <br /> B. CONSTRUCTION U 1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> PIPE <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL <br /> CHLORIDE(PVC)AATtNGA U 4 FIBERGLASSNOL COMPATIBLE WI <br /> 5 ALUMINUM A U 6 CONCRETE A U <br /> CORROSION IC PROTECTION A U 95 UNKNOWN A U 99 OT ER 10 CATHODIC PROTECTION A U 9 GALVANIZED STEEL A U 3 INTERSTITIA 99 OTHER <br /> 1 AUTOMAT IC LINE LEAK DETEC"R ❑ 2 LINETIGHTN. TESTING ❑ MON70PING <br /> D. LEAK DETECTION ❑ <br /> V.TAN EAK DETECTION <br /> 7 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VAPOR MONITORING❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING <br /> ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 95 UNKNOWN ❑ 99 OTHER <br /> VI.TANK CLOSURE INFORMATION3.WAS TANK FILLED WITH YES [:] NO❑ <br /> 2.ESTIMATED ODANTITY OF GALLONS INERT MATERIAL? <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/VR) SUBSTANCE REMAINING <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGEE IS TRUE AND CORRECT <br /> APPLICANTS NAME <br /> (PRINTED a SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW TAIzAa -NK <br /> COUNTY# JURISDICTION# FACILITY# <br /> STATE LDA _ 2�1PERMIT EXPIRATION DATE <br /> PERMIT MBS PERMIT APPROVED BY/DATE <br /> &R4 <br /> FORM a ce 9ol THIS FORM MUST BE ACCOMPANIED BY A PERMR APPLICATION-FORMA,UNLESS A CUNT RM A HA EE F,[J (LED. Fo99ma <br />