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f <br /> STATE OF CALIFORNIA <br /> STATIC WATBR RESOURCES CONTROL BOARD Y Via. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FOAM 13 Y • <br /> r` <br /> P COMPLETE ASEPARATE FORM FOR EACH TANK SYSTEM. <br /> MARK ONLY ❑ t NEW PERMIT RENEWAL PERMIT S CHANGE OF IWDAUATION © T PERMANENTLY:C€93 ON SITE <br /> ONE ITEM Ej�_2 INTERIM PEAMr: 4 AMENDEb PERAAM O 6 TEMPOPARY TANK CLOSURE a 9 TANK REMOV-.- REQ <br /> DBACIR FACILITY NAME WHEAE'TANK IS INST&LED: <br /> L TANK DESCAIPTION COMPLETE AL:-I1IE4S-SPECIFY IF UNKNOWN <br /> A.OWWER's TANK 1.b_• y I�_ B.MANUFAGTUREO SY: W f`�I <br /> G.DAVE INSTALLED(MIOIL7AY/YEAR) � } 0.TANK CAPACCIY IN GALLONS: 550 <br /> ILTATIKCONTENTS IFA-115MAHIc;,COU PL%-MITEM C. <br /> A. i MOTOR VEHICLE FUEL A OIL14REGULAR 3 DIESEL <br /> B' C' ❑ UNLEADED at.,'ION tiAS <br /> ❑ ; GABAHDL <br /> 2 PETROLEUM W BMPTv p 1 PRODUCT ❑ 1b PREMIUM - k,---iANDL <br /> Q UEL <br /> 3 CHEMICAL PRODUCT 95 UNKNOWN �Z WASTE 0 LLE D D� 5 JET FE49 <br /> 2 9a OTHER {DESCRIBC i"zM a 9ELOW1 <br /> M IF(A.!)IS NOT MARKED.ENTER NAME OF S4:`3STA'ICE STORED �C�J� I C.A.&a: 000-2,05-9 <br /> ITL TANK CONSTRUCTION MARK CKEISeYCNRY[v80)IESA B ANpC AND ALt,T>igTAP?LESINBG%DANDE �l�n�T rs r-AA /rte.,&, L 6� <br /> A. TYPE OF 231* t DOUBLE WALL 3 SINGLE MALL WITH EXTERIOR LINER BS UNKNOWN <br /> SYSTEM 0 2 SINGLE WALL � 4 SECOICARY WNTANMENT (VAULTEb TAME B9 OTHER <br /> B. TANK 71 1 BARE STEEL 7 2 STAINLE39$1EEt 3 FQEMOLASS 4 STEEL CLAD WIRBERGLASS REI S-0-ICZrD PLASTIC <br /> MATLRIAL ❑ S CONCRETE A POLYVINYL CHLORIDE T ALUMINUM ❑ B IW%METHANOL COMPATIBLEW0 <br /> (Pdm>tlyTmk} 9 DRCNZE to OALVANIZO STEEL O 68 UNKNOWN ❑ N OTHER _ <br /> ❑ t RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING E] • PHENOLIC L9iNG <br /> L <br /> C 1 KINc 4R s GLASS UNIM • UNLIWD T1s UNKNOWN ❑ 9S OTHER <br /> NIN <br /> IS LINING MAltR14L COLIFATdU WITH IN%UrrHANOL T YES NO— <br /> D.CDARC)SK}N L:l I POLYETHYLENE--v ❑ 3 WATHO � 2 VINYL WRAP PW4 FIBERGLASS REINFORCED PLA$+C <br /> PROTECTION ® S CATNDOIePROTEEL'TION 01 NONE 9s UN)rNm- ❑ tIa OTHER <br /> E SPILL AND OVERFILL SPLL OpNTANMENT ffzTZI.W(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED V9AR} <br /> Dul <br /> W.PILING INFORMATION CIRCLE A IFABDYEEGROUNDt}R U IFUNDEWAKW D.AMWAPPLICARLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESBURE A a GRAVITY A u 00 OTHER <br /> Ii. CONSTRUCTION A U 1 SM10LE WALL A 01 2 DOIiLE WALL A V 9 LINES TJIGWI1 A U IIS UNKNOWN A U 0 OTHER <br /> C. MATERLAL AND A U t BARE stEEL A U R STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVq A dD 4 FIBERGLASS PIPE - <br /> CORROSION A U 5 ALUMIA d A d 4 ODNCRE'TE A U 7 STEELY&MATM A V 4 mm METHANOL C,OMPATImwiFRp <br /> pRCTECTION A U a GALVANIZED STEEL A u 10 CAtHWICPROTECTION A u 01 UNKNOWN <br /> A U s>o OTHER <br /> D. LM DETECTION ❑1 AUTGMATTCLINE LEAK DETEum 0 o LNE TIGHTNE9s Taira wgsmlwmommmm <br /> ❑yo OCHER <br /> V.TANK LEAK DETECTION -- <br /> F-1 I vmuAL C$4;rx ❑ 2 NVEwow RECONCMJA'71CaN ® 7 VADOZB MONmmnwG 0 4 AUTOMATIC TAW GAIJIGM s GROUND WATER MONITORING <br /> 0 0 TANK T=?INQ T INTER6TT11ALMONIiORM-> ,❑ s11 w)mE ❑ pS U mom 0 a OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> L ESTIMATED DATE LOT USW @=AYNM, I-1 ESTIMATED OUAIf M OF i WA8 TANK FILLED WM4 <br /> SUBSTANCE REMANNG G1UldN8 INERT MATEAUIL? M ❑ NO <br /> 7-NIS FORAO HAS BEEN COUPLETED UN(DEA PEMALTT r OF A,ERjVgy D To TNF 6E3 MAY XN0*tBD F_IS TRUE AArD CORRECT <br /> APPLKTANM NAME TE <br /> fl 14M i& <br /> 1+�I+iBly a Rlew►111 <br /> . �Z' 412t:�l <br /> LOCAL AGENCY USE ONLY TNir sTATE I.D.NUMBER IS COMPOSED GFTHE FOUR NUMBERS BELOW <br /> COUNTY ax JURLRD1CT1pN R . . _ FACILITY TANK s <br /> STATE 1.t7.# m L I It 7 o i ZI <br /> PEpMIT HUMP ER PERMIT APPROVED BYIDATE AATM DATE <br /> THIS FORM MUST BE ACCOMPANILD BY A PERMIT APPLICATION-,FORA[A,UNLESS A CURRENT FORA A HAS BLEN FIL A <br /> FORM (12•p)y FILL TM 1111M WITH T L AGENCY UIPLEMEMING THE UNDERGROUND STO K REGULATIONS <br /> L00/900fA 1I0 'I13HS OCTHL910TE XVd LT:TT 96/9T/T0 <br />