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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD DEC <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORVqqrjNi E . ..... H <br /> PER <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANEN�/CLO, <br /> ONE ITEM F7 2 INTERIM PERMIT F--] 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REM ED <br /> DBA OR FACILITY NAME WHERE TANK IS INSTALLED: /1416 0 m lld?�' <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK 1.D. B. MANUFACTURED BY: <br /> C. DATE INSTALLED(MO/DAYNEAR) D. TANK CAPACITY IN GALLONS: <br /> Il.TANK Cq�TENTS IF A-1 IS MARKED,COMPLETE ITEM C. <br /> A. &�l MOTOR VEHICLE FUEL F-] 4 OIL B. C. E71.REGULAR 1 DIESEL 6 AVIATIONGAS <br /> 2 PETROLEUM F-1 80 EMPTY F7 1 PRODUCT lbPREMIUM 7 METHANOL <br /> UNLEADED F-] 5 JET FUEL <br /> F-] 3 CHEMICALPRODUCT 95 UNKNOWN 2 WASTE 2 LEADED 99 OTHER (DESCRIBE IN ITEM D. BELOW) <br /> D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.#: <br /> TANK CONSTRUjC'*ION <br /> A. TYPE OF 1 DOUBLE WALL F-] 3 SINGLE WALL WITH EXTERIOR LINER E:l 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL F--1 4 SECONDARY CONTAINMENT (VAULTEDTANK) 99 OTHER <br /> B. TANK I BARE STEEL F-] 2 STAINLESS STEEL [j?r2l FIBERGLASS 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> MATERIAL F--] 5 CONCRETE 6 POLYVINYL CHLORIDE F-] 7 ALUMINUM 8 1009/6 METHANOL COMPATIBLEW/FRP <br /> (PrimaryTank) 0 9 BRONZE 10 GALVANIZED STEEL [�:] 95 UNKNOWN 99 OTHER____ <br /> F--j 1 RUBBER LINED F-] 2 ALKYD LINING F--] 3 EPDXY LINING 4 PHENOLIC LINING <br /> C.INTERIOR F-] 5 GLASS LINING F-] 6 UNLINED F--j 95 UNKNOWN 99 OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— <br /> D.CORROSION F--] 1 POLYETHYLENE WRAP F-] 2 COATING F-] 3 VINYL WRAP [:?"4 FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION [::] 5 CATHODIC PROTECTION F-] 91 NONE F-] 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR)—["-7,-- OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IFABOVE GROUND opu IFUNDERGROUND,BOTH IFAPPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION AV 2 PRESSURE A U 3 GRAVITY A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALL A&) 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER <br /> C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 04 FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 10(r/. METHANOL COMPATIBLEW/FRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER <br /> D. LEAK DETECTION f�?l"AUTOMATZ LINE LEAK DETECTOR r;?l LINE TIGHTNESS TESTING 1�i�MONFORING D 99 OTHER <br /> V.TANK LEAK DETECTION .01 <br /> F-� 1 VISUAL CHECK [;o<2 INVENTORY RECONCILIATION F-] 3 VADOZE MONITORING [���4AUTOMATIC TANK GAUGING [:] 5 GROUND WATER MONITORING <br /> E::] 6 TANK TESTING IF--i-1 INTERSTITIAL MONITORING F] 91 NONE E] 95 UNKNOWN E:l 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [::] NO <br /> INING GALLONS INERT MATERIAL? <br /> T141S FORM HA S BEEN COMPLETED UNDZR PENAkr&I9F-PoJURY,AND TO THE BES T OF MY KNOWLEDGE, IS TRUE AND CORRECT <br /> APPLICANT'S NAME DATE <br /> (PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTHLP6UR NUMBERS BELOW <br /> COUNTY# JURISDICTION# FACILITY# TANK# <br /> PERMIT NUMBER PERMIT APPROVED BYIDATR,�.��MIT EXPIRATION DATE <br /> FORM o (7-vv THIS FORM MUST BEACCOMPANIED aY4PERMIT APPLICATION'FORM 4UNLESS ACURRENT FORM A HAS BEEN FILED. <br /> nm00mmo <br />| . � <br />