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STATE OF CAUFDRMA s STATE WATER RESOURCES CONTROL BOARD W U NI)STORAGE TANK PERMIT APPLICATION-,FOR B COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM MAR(ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONEREM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED /09 DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 4*�a " a4a--� I. TANK DESCRIPTION cDMPLETE ALL ITEMS SPECIFY IF UWNOWN A.OWNER'S TANK L D.s B. MANUFACTURED SY: C. DATE INST (MOIDAY/YEAR) O.TANK CAPACITY IN GALLONS: O.TANK ENTS IFA-1ISMARKED.COMPLETEITEMC. 3 � 1 MOTOR VEHICLE FUER. F-14 OIL 8. 0/ C. og to REGULAR UNLEADED DIESEL ❑ 8 AVIATIONGAS 2 PETROLEUM F-160 EMPTYPRODUCT F-1lb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED H S T FUEL ❑ 3 CHEMICAL PRODUCT ❑ 96 UNKNOWN El WASTE ❑ 2 LEADED 9p.EOTHER(DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.s: TIL TANK CONSTRUCTION MARK ONE r EM ONLY IN BOXES A.B.AND C.AND ALL THAT APPLES IN BOX D AND E A. TYPE OF ❑ I DOUBLE WALL ❑ 3 U40LE WALL WITH EXTERIOR LINER Q 96 UW140WN SYSTEM ❑ 2 SWGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 09 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 6 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 100%METHANOL COMPATIBLE W/FRP MdMWYTX*) ❑ 9 BRONZE ❑ 10 GALVANIZED STEER. ❑ 95 UWNOWN ❑ 09 OTHER ❑ 1 RUBBER LOW ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ S GLASS LINING ❑ 6 UNLINED ❑ 96 LNWN(YW N ❑ 90 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? YES_ NO— D.CORROSION ❑ / POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ S CATHODIC PROTECTION ❑ 91 NOW ❑96 UNKNOWN ❑ 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EOUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF A90VE GROUND OR U IF UNDERGROUND.BOTH E APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A V 2 PRESSURE A U 3 GRAVITY A U 99 OTHER 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 / BARE STEEL A U 2 STAMLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL.W/COATING A V 8 100!6 METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 96 UNKNOWN A U 99 OTHER D. LEAK DETECTION ❑ / AUTOMATIC LINE LEAK DETECTOR ❑ :! LINE TIGHTNESS TESTING ❑ MoWronffla ❑99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 YNVEMORY REOONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING❑ 5 GROUND WATER MONITORING ❑ 6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING ❑ 91 NONE ❑ 96 UNKNOWN Q 99 OTHER VL TANK CLOSURE INFOMATKN(I 1.ES T1M OAJE LAR (MWDAYNR) 2.ESTI MATEDQUANTITY OF 3.WAS TANK FLLED WITH YE3NO SMTANCE REMA14M 1ALLONS INERT MATERIAL? ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG&IS TRUE AND CORRECT APPLICANT'S NAME DATE (PftNTED&8XL4ATUPIM LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNT`!# JURISDKCTK M NI FACK M s TANK NI STATE I.D.# PERMIT NUMBER PERMIT APPROVED BVIDATE PERMIT EXPIRATION DATE FORMS (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION.FORM A,UNLESS A CURRENT FORM A HAS BEEN FLED.