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STATE OF CALIFORNIA °s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM El e =0 COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM J .J �i fit(�• MARK ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED ONSITE ONE REM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 1 /7 B TANK REMOVED �.. DBA OR FACILITY NAME WHERE TANK IS INSTALLED: I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK I.D.# B. MANUFACTURED BY: 1 C. DATE INSTALLED(MO/DAY/YEAR) D. TANK CAPACITY IN GALLOONS: Q�O ILTANKCONTENTS IFA-11S MARKED,COMPLETE ITEM C. REGULAR A1 MOTOR VEHICLE FUEL ❑ 4 OIL B. Icy C. ❑ 1aUNLEADED ® 3 DIESEL ❑ g pyyL GAS 2-PETROLEUM ❑ 80 EMPTY IXI 1 PRODUCTa lb PREMIUM 4 GASAHOL ❑ 7 METHANOL 5 JET F-13 CHEMICAL PRODUCT ❑ 95 UNKNOWN �O 2 WASTE ❑ 2 LEADED UNLEADED 99 OTHERL(DESCRIBE IN ITEM D.BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S,#; 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A,B.AND C.AND ALL THAT APPLES IN BOX D AND A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER I}-95 UNKNOWN SYSTEM I�' 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANq U 99 OTHER B. TANK 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100% METHANOL COMPATIBLE W/FRP (PrimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED.STEEL 95 UNW40WR ❑ 99 OTHER ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑y 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING ❑ 6 UNLINED 17C 1 95 UNKNOWN ❑ 99 OTHER LINING 7'-C IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 01 NONE v_ YE- -x 95 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(VEA OVERFILL PREVENTION EQUIPMENT INSTALLED rfFAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION U 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION. A®1 SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH - UNKNOWN A U 99 OTHER C. MATERIAL AND A4t 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLWNYL CHLORIDE(PVC)A` 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION l(av-UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ 1 AUTOMATIC LINE LEAK DETECTOR 02 LINE TIGHTNESS TESTING ❑ 3 NIENSTITIAL NDKRORNG V.TANK LEAK DETECTION 0 1 VISUAL CHECK ❑ 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER MONITORING 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE -�96 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION 1,ESTIMATEDDATE LASTU ED(MO/DAY RC+ Cilp 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES X NO SUBSTANCE REMAINING GALLONS INERTMATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, ISKTRUE AND CORRECT APPLICANTS NAME DATE IPO a SMaNA101117, -r..-- _�A'I-Sr -�= G-&-qs LOCAL AGENCY USSEEE OFCNLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# - TANK#QQ STATE I.D.# m = FFTT I -L111lplsi-5llolq PERMIT NUMBER PERMIT APPROVED BY/DATE PERMIT 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 FORM 8 (1291) FORDM43-Ra